Documente Academic
Documente Profesional
Documente Cultură
1. ANAMNESIS:
Identificacin:
Apellidos: ______________________________ Nombres: ______________________________
Tipo de identificacin: CC ___ / TI ___ / CE ___ N:___________________________________
Edad: ______ Sexo: F___ / M____ Orientacin sexual: ________________________
Grupo sanguneo: ____ RH: ____ Estado civil: __________ Nacionalidad:
_______________
Fecha de nacimiento: ____________ Lugar de nacimiento: ____________________________
Lugar de procedencia / Otros lugares donde ha vivido: __________________________________
Lugar de residencia: ______________ Direccin: ________________________ Estrato: _____
Telfono: ____________ Nivel de escolaridad: _______________ Religin:
________________
Fuente de la historia:
Fuente de referencia:
Entrevistador:
- Traumticos: ________________________________________________________________
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- Farmacolgicos: _____________________________________________________________
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- Inmunizacin: _______________________________________________________________
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- Alrgicos: __________________________________________________________________
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- Transfusionales: _____________________________________________________________
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- Sexuales: __________________________________________________________________
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- Txicos:
Fuma: S___ No___, #cig/da__________.paq/ao_____________
Bebe: S___ No___, inicio______, frecuencia_________, cantidad__________________________
Narcticos: S___ No___, cantidad________, frecuencia________________________
Energizantes: S___ No___, cantidad________, frecuencia_______________________
Otros: S___ No___ Cal?________________________________________________________
Ginecoobsttricos: G __ P __ A __ C __ V __ M __ E __.
- FPR: ___________ FUR : _________ Ciclos Menstrual : __________.
- Inicio de la vida sexual: _______________. Inicio de vida obsttrica: _______________
- Menopausia :___________________________________________________
- Citologas:__________________________________________
- Mtodo de planificacin familiar: __________________________________
- ETS
Hospitalarios:___________________________________________________________________
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Nutricionales:___________________________________________________________________
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Familiares: _____________________________________________________________________
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Ocupacionales: _________________________________________________________________
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Socioeconmicos: _______________________________________________________________
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Sistema neurolgico:
- Cefalea:
- Vrtigo:
- Sncope:
- Convulsiones:
- Temblores:
Vison:
Agudeza visual: _____________________________________
Amaurosis: ________________________________________
Fotofobia: __________________________________________
Lagrimacin: _______________________________________
Epifora: ____________________________________________
Diplopas: __________________________________________
Escotomas: _________________________________________
Fotopsias: __________________________________________
Flotadores en el vtreo: ________________________________
Dolor ocular (retro u orbicular): ________________________________________
Odo:
Otalgia: ____________________________________________
Otorrea: ___________________________________________
Otorragia: __________________________________________
Cofosis: ___________________________________________
Paracusia: _________________________________________
Acufenos: __________________________________________
Tinnitus: ___________________________________________
Nariz:
Obstruccin nasal: ___________________________________
Rinorrea: ___________________________________________
Rinoliquia__________________________________________
Anosmia: __________________________________________
Cacosmia: _________________________________________
Parosmia: __________________________________________
Epistaxis: __________________________________________
Boca:
Odontalgia: _________________________________________
Queilitis: ___________________________________________
Gingivitis: __________________________________________
Gingivorragia: _______________________________________
Glositis: ____________________________________________
Glosodinia: _________________________________________
Tialismo: ___________________________________________
Asialia: ____________________________________________
Odinofagia: _________________________________________
Disfagia: ___________________________________________
Xerostoma: ________________________________________
Halitosis: ___________________________________________
Agusia: ____________________________________________
Paragusia: _________________________________________
Cuello:
Dolor cervical: _______________________________________
Dolor msculo esqueltico: ____________________________
Masas: ____________________________________________
Torax:
Dolor torcico: ______________________________________
Mamas:
Mastodinia: _________________________________________
Telorrea: ___________________________________________
Galactorrea: ________________________________________
Sistema cardiovascular:
Disnea: ____________________________________________
Palpitaciones: _______________________________________
Dolor precordial: _____________________________________
Cianosis: ___________________________________________
Sistema respiratorio:
Polipnea: __________________________________________
Taquipnea: _________________________________________
Bradipnea: _________________________________________
Batipnea: __________________________________________
Tos: ______________________________________________
Sistema gastrointestinal:
Acolia: _____________________________________________
Acoria: ____________________________________________
Agrieras: ___________________________________________
Anorexia: __________________________________________
Apetito: ____________________________________________
Bulimia: ____________________________________________
Constipacin: _______________________________________
Diarrea: ____________________________________________
Disfagia: ___________________________________________
Disgeusia: __________________________________________
Disquesia rectal: _____________________________________
Dolor abdominal: ____________________________________
Eructo: ____________________________________________
Esofagorragia: ______________________________________
Gastrorragia: _______________________________________
Hbito intestinal: _____________________________________
Hematemesis: ______________________________________
Hematoquesis: ______________________________________
Hemorragia digestiva: ________________________________
Hiperorexia: ________________________________________
Ictericia: ___________________________________________
Malacia: ___________________________________________
Melanemesis: ______________________________________
Melenas: ___________________________________________
Meteorismo: ________________________________________
Molestias ano rectales: ________________________________
Pujo: ______________________________________________
Tenesmo: __________________________________________
Encoprexis: _________________________________________
Nuseas: __________________________________________
Obstipacin: ________________________________________
Parorexia: __________________________________________
Pica: ______________________________________________
Pirosis: ____________________________________________
Polifagia: ___________________________________________
Rectorragia: ________________________________________
Regurgitacin: ______________________________________
Sangre oculta: ______________________________________
Sitofobia: __________________________________________
Vmito: ____________________________________________
Sistema urinario:
Dolor: _______________________________
Alteraciones en el aspecto de la orina: __________________________________________
Trastornos en la eliminacin de la orina: __________________
Alteraciones del chorro de la orina: _____________________________________________
Sistema endocrino:
Alteraciones de la hipfisis: _____________________________________
Alteraciones de la tiroides: _____________________________________
Alteraciones de las adrenales: _____________________________________
Alteraciones de las gnadas: _____________________________________
Alteraciones del pncreas: _____________________________________
Piel y anexos:
Prurito: _____________________________________
Otros: _______________________________________