1. NUME SI PRENUME :..........................................................................................................................

2. VARSTA :.......... 3. LOC PREZENTARE :..........................................................................

4. MOTIVELE INTERNARII :.....................................................................................................................
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5. ANTECEDENTE
 AHC ( MTF -> boli de inima , plamani , ficat , rinichi , stomac , diabet , cancer , tensiune? )
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 FIZIOLOGICE (Gr sg : Rh: )
 !FEMEI :.............................  nr avorturi:........................
 menarha:...........................  nr sarcini:...........................
 menopauza:.......................  nr nasteri(N/C):.................
 menstruatie:......................  kg fat:................................
 PATOLOGICE........................................................................................................................................
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6. CONDITII DE VIATA SI MUNCA :
 locuieste : singur / cu familia  lucreaza :..................................
 unde: rural/urban
7. COMPORTAMENTE :
 alcool:......................................  cafea:.......................................
 fumator :..........................................................................................................................
8. MEDICATIE:.........................................................................................................................................
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9. ISTORICULBOLII:
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EXAMENUL CLINIC GENERAL :

I.EXAMENUL OBIECTIV :

1. Stare generala :
2. Stare de nutritie : ...............................*Kg...................*h................*BMI(kg/h2)..........*CA.........
3. Facies : normal/simetric/asimetric/tumultos/vultos/.................................................................
4. Tegumente : normal colorate/....................................................................................................
cicatrici:..................................................... edeme: pufoase/dureroase/.....................................
5. Mucoase : normal colorate/.........................................................................................................
6. Fanere : normal implantate/........................................................................................................
7. T conjunctiv adipos : normal/in exces : ......................................................................................
8. Sistem ganglionar : *NU : sistem ganglionar superficial nepalpabil/
*DA: zona : submandibular/mentonier/retroauricular/suboccipital/supraclavicular
laterocervical/axilar/san/inghinal/fosa poplitee
consistenta:............................................ dimensiune:..........................................
dureros:.................................................. mobil:....................................................
9. Sistem muscular : normoton/normotrof/normokinetic/hipotrof/hipokinetic/...........................
10. Sistem osteoarticular : * - probleme : aparent integru , clinic si functional
* + probleme :...............................................................................................................................

II.APARATUL RESPIRATOR

I: torace : normal conformat/cifotic/scoliotic/.................. excursii costale simtrice bilaterale/.............

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P: 33 -> vibratii normale/slabe cu transmisie bilaterala /.........................................................................

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P: sonoritate pulmonara normal transmisa bilateral/...............................................................................

A: murumur vezicular fiziologic prezent bilateral/raluri.......................................................FR:...............

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III.APARATUL CARDIOVASCULAR

I:.................................................................................................................................................................

P: soc apexian:...........................................................................................................................................

P: aria matitatii:.........................................................................................................................................

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A: zgomote cardiace : ritmice/aritmice bine/slab batute ......................................................................

.....................................................................TA ortostatism:................. TA clinostatism:..........................

Puls:pedioasa.............retromaleolar................poplitee..............inghinal.................carotida...................