1.

DATOS DE FILIACIÓN:

Nombres y Apellidos: ___________________________________________________

Edad: ________

Estado Civil: ________________

Etnia: _____________

Religión: ___________

Lugar de nacimiento: ______________

Lugar de residencia habitual: ______________ Dirección: _____________________________

Nacionalidad: ____________

Genero: _____________

Grupo Sanguíneo: ___________

Instrucción: ________________________ Ocupación: ___________________________

2. MOTIVO DE LA CONSULTA:

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3. ENFERMEDAD ACTUAL:

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4. REVISIÓN POR APARATOS Y SISTEMAS:

Estado general: ______________________________________________

Piel y anexos: ________________________________________________

Nariz: ______________________________________________________

Respiratorio: ________________________________________________

Cardiovascular: ______________________________________________

Gastrointestinal: _____________________________________________
Anoperineal: ________________________________________________

Genitourinario: ______________________________________________

Endrocrino metabolico: _______________________________________

Hemolinfatico: ______________________________________________

Osteomuscular: _____________________________________________

Neurológico: ________________________________________________

5. ANTECEDENTES PERSONALES PATOLÓGICOS:

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5.1. Antecedentes quirúrgicos:

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5.2. Antecedentes gineco-obstétricos

Menarquia: _____________________

Inicio vida sexual: ________________

Enf. De transmisión sexual: _____________________________

Gestas (___) Partos (___) Cesáreas (___) Abortos (___) Hijos vivos (___)

FUM: _______________

Uso de Métodos Anticonceptivos: Si ______ No _______

¿Cuál? ________________________________________

5.3. Alergias

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5.4. Inmunización

COVID-19: ________________________

6. ANTECEDENTES PERSONALES NO PATOLÓGICOS

Alimentario: ____ veces al día

Miccional: ____ veces al día

Defecatorio: ____ veces al día

Alcoholismo: __________________

Tabaquismo: __________________

Drogas: _________________

Sueño: ____ horas

7. ANTECEDENTES PATOLÓGICOS FAMILIARES:

Padre: Vivo Si____ No____

Enfermedades que padece: _______________________________________

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Madre: Viva Si____ No____

Enfermedades que padece: ________________________________________

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Hermanos: ¿Cuántos? ______ Vivos _____

Enfermedades que
padecen: ________________________________________________________________________
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8. CONDICIONES SOCIO-ECONOMICAS:

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9. EXAMEN FÍSICO:

Signos vitales:

T.A.________ FC _________ FR ________ T°______ Peso_______ Talla_______ SO2______

Paciente:

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Piel:
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Cabeza y Cuello:
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Tórax:

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Pulmones:

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Corazón:

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Abdomen:

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Extremidades:

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