UNIVERSIDAD COOPERATIVA DE

FACULTAD DE MEDICINA SEMIOLOGIA

COLOMBIA

IPS:_____________________ CIUDAD: _________FECHA Y HORA: ______________________

NIT: ___________________ CODIGO HABILITACIÓN : ____________________

GRUPO DE SERVICIOS __________________ No. ___________________

MODALIDAD DEL SERVICIO : ______________ ENTORNO DE ATENCIÓN: ____________
IDENTIFICACION
PRIMER NOMBRE:_______________________SEGUNDO NOMBRE: _________________________
PRIMER APELLIDO: _____________________ SEGUNDO APELLIDO: _______________________
TIPO DE IDENTIFICACION: _______________ No. IDENTIFICACION: ___________________________
NACIONALIDAD: ________________________NOMBRE DEL PAÍS: __________________________
FECHA NACIMIENTO: ___________________ EDAD: __________
SEXO BIOLÓGICO: ______________________ IDENTIDAD DE GÉNERO: _____________________
OCUPACIÓN: __________________________ ESTADO CIVIL;_____________________
OPOSICIÓN A LA PRESUNCIÓN LEGAL DE DONACIÓN: _________ FECHA SUSCRIPCIÓN DOCUMENTO: ____
DOCUMENTO DE VOLUNTAD ANTICIPADA: __________________ FECHA SUSCRIPCIÓN DOCUMENTO: ____
CATEGORÍA DISCAPACIDAD ______________
PERTENENCIA ETNICA: ___________________RELIGION: ______________ ESCOLARIDAD: ________
PAIS DE RESIDENCIA: ___________________ MUNICIPIO DE RESIDENCIA: __________________
ZONA TERRITORIAL DE RESIDENCIA: _______
NATURAL:_____________________ RESIDENCIA:____________________ PROCEDENCIA:________
DIRECCION: ________________________________ TELEFONO:________________________
REGIMEN EN EL SGSS:____________________ENTIDAD :____________________ TIPO AFILIADO: __________
ACOMPAÑANTE:________________________ RESPONSABLE:_______________________________
DIRECCION TELEFONO RESPONSABLE:_______________________ PARENTESCO RESPONSABLE: _________________
VIA DE INGRESO DEL USUARIO AL SERVICIO DE SALUD: _________________________________
CAUSA EXTERNA:_______________________ FINALIDAD:____________________________________
TRIAGE: _____________ FECHA Y HORA: ________________________________
MOTIVO DE CONSULTA:____________________________________
ENFERMEDAD ACTUAL;
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Sede Santa Marta

 UNIVERSIDAD COOPERATIVA DE
FACULTAD DE MEDICINA SEMIOLOGIA
COLOMBIA

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ANTECEDENTES PERSONALES
ANTECEDENTES PATOLOGICOS:__________________________________________________________________
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ANTECEDENTES FARMACOLOGICOS: _________________________________________________________________
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ANTECEDENTES QUIRURGICOS: ____________________________________________________
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ANTECEDENTES INMUNOLOGICOS :__________________________________________________
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ANTECEDENTES ALERGICOS:_____________________________________________________________________
ANTECEDENTES TRAUMATICOS:_______________________________________________________________
ANTECEDENTES TRANSFUSIONALES Y HEMOCLASIFICACIÓN:________________________________________
HOSPITALIZACIONES:_____________________________________________________________________
ANTECEDENTES PSICO SOCIALES
MEDIO AMBIENTE:
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ESTILO DE VIDA:
HABITOS SALUDABLES:___________________________________________________
HABITOS NO SALUDABLES: _____________________________________________________________
ANTECEDENTES OCUPACIONALES:________________________________________________________________
ANTECEDENTES OBSTETRICOS;
M: _________ FUM;______________CICLOS:__________ DURACION:_____INICIO VIDA SEXUAL:_____
G: ____ p:_____ A:______ C:______ MORTINATOS:___________ HIJOS VIVOS:__________
PLANIFICACION:_____________________ F ULTIMA CITOLOGIA:_____________ RESULTADO:_____________

ANTECEDENTES FAMILIARES
PADRE:____________________________________ MADRE:_______________________________
HERMANOS_______________ HIJOS:_________________
OTROS:__________________________________________________________________________________

REVISION POR SISTEMAS

SINTOMAS GENERALES __________________________________________________________________________

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PIEL Y ANEXOS __________________________________________________________________________

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CABEZA, CARA, CUELLO __________________________________________________________________________

Sede Santa Marta

 UNIVERSIDAD COOPERATIVA DE
FACULTAD DE MEDICINA SEMIOLOGIA
COLOMBIA

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ORGANO DE LOS SENTIDOS :______________ _________________________________________________________
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BOCA Y FARINGE _________________________________________________________________________
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CARDIO PULMONAR _________________________________________________________________________
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ABDOMEN ________________________________________________________________________
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GENITOURINARIO _________________________________________________________________________
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LOCOMOTOR EXTREMIDADES:______________________________________________________________________
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NEUROPSIQUIATRICO _________________________________________________________________________
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EXAMEN FISICO
SIGNOS VITALES TA: ______________ PULSO:__________ TEMP:_________F.RESP.________________
SATURACION O2:______PESO:__________ TALLA:_________ IMC:_______________

ESTADO GENERAL:___________________________________________________________________________
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PIEL Y ANEXOS ;___________________________________________________________________________
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CABEZA, CRANEO, CARA, CUELLO :____________________________________________________________
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OJOS: ______________________________________________________________________________________
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NARIZ OLFATO_________________________________________________________________________________
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Sede Santa Marta

 UNIVERSIDAD COOPERATIVA DE
FACULTAD DE MEDICINA SEMIOLOGIA
COLOMBIA

OIDOS _______________________________________________________________________________________
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BOCA:_______________________________________________________________________________________
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TORAX:______________________________________________________________________________________
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ABDOMEN:___________________________________________________________________________________
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GENITO URINARIO:____________________________________________________________________________
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LOCOMOTOR
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NEUROLOGICO:________________________________________________________________________________
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Sede Santa Marta

 UNIVERSIDAD COOPERATIVA DE
FACULTAD DE MEDICINA SEMIOLOGIA
COLOMBIA

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EXAMEN MENTAL :_________________________________________________________________________________
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DIAGNOSTICO:
DIAGNOSTICO PRINCIPAL DE INGRESO ______________________
DIAGNOSTICO RELACIONADO : ______________________
DIAGNOSTICO RELACIONADO : ______________________
DIAGNOSTICO RELACIONADO : ______________________
CIE 10: ________TIPO DIAGNOSTICO: __________
CIE 10: ________TIPO DIAGNOSTICO: __________
CIE 10: ________TIPO DIAGNOSTICO: __________
CIE 10: ________TIPO DIAGNOSTICO: __________

PRONOSTICO
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ORDENES MEDICAS
NO FARMACOLOGICAS
1:_____________________________________2:________________________________________________
3._____________________________________4;________________________________________________
5:_____________________________________6.________________________________________________
FARMACOLOGICAS
1. ______________________________________________________________________________
2. ______________________________________________________________________________
3. ______________________________________________________________________________
4. ______________________________________________________________________________
5. ______________________________________________________________________________
PARACLINICOS
1. ______________________________________________________________________________
2. ______________________________________________________________________________
3. ______________________________________________________________________________
4. ______________________________________________________________________________
5. ______________________________________________________________________________

IDENTIFICACIÓN DEL TALENTO HUMANO EN SALUD

NOMBRE Y FIRMA DEL PROFESONAL :______________________________

Sede Santa Marta