MASCULINO

Fecha_________________Nombre_________________________________________________M

F. Nacimiento ________________ Edo. Civil _____________ Escolaridad _________________

Num. hijos_______________ Peso __________Estatura ___________ T. Arterial ____________

Tipo de sangre _____________ Domicilio _____________________________________________

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Padec.hereditarios________________________________________________________________

Tratamiento actual _______________________________________________________________

Dolor (Tipo/zona)___________________________________Desde cuando__________________

Inflamación______________________________Entumecimiento__________________________

Fiebre____________________Escalofrios_____________________Gusto___________________

Temp.extremidades________________Espalda_________________Vientre_________________

Sueño _____________________ Como duerme_______________________________________

Desayuno________________________________________________________________________

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Comida _________________________________________________________________________
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Cena____________________________________________________________________________

Entre comidas____________________________________________________________________

Cuidados prep.alimentos___________________________________________________________

Donde come ______________________Veces/día ____________Como mastica______________

Apetito__________________________________Sed_____________________________________

Alcohol ______________________Tabaco___________________Café______________________

Orina___________________________________________________________________________

Evacuación______________________________________________________________________

Ejercicio _______________________________Respiración_______________________________

Transpiración _________________________ Edo. Animo______________________________

Trabajo remunerado______________________________________________________________

Tiempo libre_____________________________________________________________________

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Traumatismos____________________________________________________________________

Interv. Quirúrgicas _______________________________________________________________

Enf. Graves o infecciosas __________________________________________________________

Enf. Venéreas ____________________________________________________________________

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Mét. Anticonceptivo ______________________________________________________________

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Apariencia________________________________Lengua________________________________

Saburra ___________________________________Olor _________________________________

Voz _________________Tipo de piel _______________________Unidad___________________

Pulsos___________________________________________________________________________

Puntos de Alarma_________________________________________________________________

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Puntos canales____________________________________________________________________

Observ. Generales ________________________________________________________________

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Diagnostico ______________________________________________________________________

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Motivo de la consulta _____________________________________________________________
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