Dra.

Nereyda Martínez Benavides

Ginecología y Obstetricia
HISTORIA CLINICA

Nombre_______________________________________________________________
Fecha ______________ Fecha de nacimiento_________________________________
Teléfono__________________ Referida por__________________________________
E mail_____________________________

Antecedentes Heredofamiliares
Diabetes Mellitus_________________________________________________________
Hipertension____________________________________________________________
Cancer________________________________________________________________
Otras_________________________________________________________________

Antecedentes Personales no patológicos

Originaria_______________________ Residente_______________________
Ocupación______________________ Escolaridad______________________
Estado civil______________________ Religión_________________________
Hemotipo_______________________ Alergias_________________________

Antecedentes personales patológicos

Enfermedades___________________________________________________________
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Quirugicos______________________________________________________________
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Trasfusiones________________________________________

Antecedentes ginecoobstetricos
Menarquia__________________ ritmo__________________________ IVSA_____ PS___
DOC CACU_______________________________ DOC MAMA________________________
MPF________________________ FUM______________
G___ P___ C___ A____
G1____________________________________________________________________
G2___________________________________________________________________
G3____________________________________________________________________
G4____________________________________________________________________
Actual_________________________________________________________________
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PEEA
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Talla ________ Peso________ IMC__________________________________________
TA_______ FC ________ FR_______ Temp_____
Exploración física
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Laboratorios
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Rastro US
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_____________________________________________________________________

IDX
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_____________________________________________________________________
_____________________________________________________________________

Plan
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 Dra. Nereyda Martínez Benavides
Ginecología y Obstetricia
SUBSECUENTE
Nombre_______________________________________________________________
Fecha ______________

Edad_____ G __ P __ A__ C__

FUM______________________

PEEA
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Signos Vitales
Talla ________ Peso________ IMC__________________________________________
TA_______ FC ________ FR_______ Temp_____

Exploración física
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Laboratorios
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Rastro US
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IDX
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Plan
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