Documente Academic
Documente Profesional
Documente Cultură
Sexo:
Grupo tnico:
Religin:
Raza:
Grupo
Sanguneo:
Estado Civil:
Lugar y Fecha de
nacimiento:
Direccin Actual:
Grado de
instruccin:
Profesin/Ocupaci
n:
Fecha de Ingreso:
Informacin
Suministrada por:
Telfonos:
Parentesco:
Confiabilidad:
Nacionalidad:
B. Motivo de Consulta:_______________________________________________
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C. Enfermedad Actual: (Aparicin, Localizacin, Intensidad, Carcter o Tipo,
Irradiacin, Agravantes, Aliviantes, Desencadenantes, Redivida/Frecuencia,
Concomitante, Negativo Pertinente)
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D. Antecedentes
D.1 Antecedentes Personales y Patologicos:
Hbitos (indicar cantidad, frecuencia y desde cuando consume):
a.Dieteticos:_________________________________________________________
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b.Alcoholicos:_______________________________________________________
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c.Cafeicos:__________________________________________________________
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d.Tabaquismo:_______________________________________________________
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e.Drogas:___________________________________________________________
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f.Sueo:____________________________________________________________
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g.Sexuales:__________________________________________________________
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h.Ejercicios:_________________________________________________________
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i.Condiciones
Higienicas:__________________________________________________________
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Enfermedades (Cuales a presentado, aparicin y sus complicaciones) y
Medicamentos (relacionados con las enfermedades anteriores, si ha ingestado
algn otro medicamento y para que, Cantidades y frecuencia).
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Alergias:____________________________________________________________
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F. Examen Fsico
Signos Vitales:
-Presin Arterial:____________________________________________________.
-Pulso:_____________________________________________________________.
-Respiracion:
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-Temperatura:
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-Peso y Talla:
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Condicin General del paciente:
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Cabeza:____________________________________________________________
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Cuello:_____________________________________________________________
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Torax:______________________________________________________________
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Abdomen:__________________________________________________________
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G. Hallazgos
Positivos:________________________________________________________
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H. Diagnostico:
Diagnostico Sindromatico:____________________________________________.
Diagnostico Anatmico:______________________________________________.
Diagnostico Funcional: _______________________________________________.
Diagnostico Etiolgico: _______________________________________________.
Diagnostico Principal:________________________________________________.
Diagnostico Diferencial:
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