HISTORIA DE SALUD DEL ADULTO No.

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FECHA:___________________ HORA:___________________

ANAMNESIS GENERAL
Nombres: ____________________________________ Apellidos: ____________________________
Edad: ___________ Género:_________ Estado civil:__________ Escolaridad: _______________________
Lugar de nacimiento: _________________________ Procedencia: ________________________________
Religión: ________________________ Institución: _________________________________________
Afiliación al SGSSS: __________________________________________________________________

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Motivo de la consulta:
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Situación actual:
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Antecedentes Personales
Patológicos: ________________________________________________________________________
Gineco obstétricos: ____________________________________________________________________
Quirúrgicos: ________________________________________________________________________
Traumáticos: _______________________________________________________________________
Hospitalarios: _______________________________________________________________________
Inmunológicos: ______________________________________________________________________
Psiquiátricos:
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Farmacológicos: ______________________________________________________________________
Tóxicos: ______________________________________________________________________________________________________

Antecedentes Familiares:
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Historia personal
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ANAMNESIS POR SISTEMAS
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EXAMEN FÍSICO
Peso__________________ Talla ________________ I. M. C. ___________________________
Relación Cintura - Cadera: _____________________________________
Agudeza Visual: ______________________
O.D. O.I. ______________________
Signos Vitales: T.A.
______________________ T°: ______________________
Respiración: _______________________________________________
Pulso: ___________________________________________________
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EXAMEN MENTAL:
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VALORACION FAMILIAR
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VALORACION REDES SOCIALES DE APOYO

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Dx de Enfermería

Intervenciones

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