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Datos demográficos:
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Motivo de consulta :
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Dx medico
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Antecedentes Familiares
Diabetes_____________________________________________________________________
Cardiovasculares ______________________________________________________________
Alergias ______________________________________________________________________
Respiratorias__________________________________________________________________
Tuberculosis __________________________________________________________________
Renales ______________________________________________________________________
ITS___________________________________________________________________________
Urinarias______________________________________________________________________
Neurológicas __________________________________________________________________
Drogas_______________________________________________________________________
Alcohol_______________________________________________________________________
Cigarrillo _____________________________________________________________________
Facies
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Vestimenta
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Actitud o posición
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Conciencia
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Memoria
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Lenguaje
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Marcha
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Movimientos Corporales
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Estado Nutricional
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Temperatura__________________________________________________________________
T/A__________________________________________________________________________
Cabeza
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Cara_________________________________________________________________________
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Ojos_________________________________________________________________________
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Nariz_________________________________________________________________________
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Boca_________________________________________________________________________
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Oído
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Tórax
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Mamas
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Tórax posterior
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Abdomen
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Genitales
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Labios menores________________________________________________________________
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sexarquia____________________________________________________________________
Anticonceptivos ________________________________________________________________
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N° de partos __________________________________________________________________
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FUR _________________________________________________________________________
FPP__________________________________________________________________________
Complicaciones
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Complicaciones
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Inmunización
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Alimentación
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Cabeza ________________________________________________________________
Tórax __________________________________________________________________
Abdomen ______________________________________________________________
Genitales_______________________________________________________________
2- Nutricional metabólica
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3- Eliminación
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Intestinal _________________________________________________________
4- Actividad – ejercicio
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5- Sueño y reposo
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6- Cognoscitivo Perceptual
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7- Autopercepción -Autoconcepto
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8- Rol
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9- Adaptación y tolerancia al estrés
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10- Sexualidad – reproducción
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11- Valores y creencias
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Observaciones
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Tratamiento Recibido
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Examen de laboratorio
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