CAPTACIÓN PRENATAL

Nombre y Apellidos: _______________________________________

Edad:_________

C.I._____________

Fecha de nacimiento:_______________

Dirección.__________________________________________

Teléfono:___________________

Fecha de elaboración de la historia: __________________

Motivo de consulta:_____________________________

HEA:
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Antecedentes patológicos personales: ___________________________________

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Antecedentes patológicos familiares:____________________________________
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Antecedentes ginecoobstetricos: Menarquía:________C/M:_____Sexarquía:_____
NPS:____ARO:_____ DIU:_____Citología:____________ Abortos:______
N° de gestas:_______
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Hábitos tóxicos:
Café:_____-Alcohol:_______Cigarrillos:____________ Tabacos:___________
Drogas:_________
Transfusiones sanguíneas:____________________________________________
Intervenciones Qx:___________________________________________________
Alergia a medicamentos:______________________________________________
Otros traumatismos:__________________________________________________
Examen físico:
TA: ________ Mmhg F.C:___lpm F.R:_____ rpm SPO2:____%
Temp: _____°c
Peso:_____kg Talla:_____cm IMC:_______kg
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Piel:______________________________________________________________
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Cardipulmonar:_____________________________________________________
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Mamas:___________________________________________________________
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Abdomen:__________________________________________________________
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Genitales:__________________________________________________________
Extremidades:______________________________________________________
Neurológico:________________________________________________________
Paraclinicos solicitados:_______________________________________________
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Próxima consulta:________________
IDx:_______________________________________________________________
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