Controlul primar al gravidei ______________________________________________________________

Data_____________________________________________________________________________________
Medicul de familie _________________________________________________________________________
Antecedente în familie și
personale___________________________________________________________________________________
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Anamneza ereditară_________________________________________________________________________
Anamneza infecțioasă _______________________________________________________________________
Anamneza allergologică _____________________________________________________________________
Patologia extragenitală ______________________________________________________________________
Toxice ____________________________________________________________________________________
Condiții de trai _____________________________________________________________________________
Condiții de muncă __________________________________________________________________________
Acuze _____________________________________________________________________________________
__________________________________________________________________________________________
Starea generală ____________________________________________________________________________
Examen general (teg., mucoase, greutate, g.l., SOM, glanda tiroidă, glande mamare) __________________
__________________________________________________________________________________________
Aparatul respirator _________________________________________________________________________
Aparatul cardio- vascular: ___________________________________________________________________
TA_____________________________________ Ps. _______________________________________________
Aparatul digestiv ___________________________________________________________________________
Ficatul ____________________________________________________________________________________
Aparatul urogenital _________________________________________________________________________
__________________________________________________________________________________________
Sistemul nervos ____________________________________________________________________________
Sistemul endocrine _________________________________________________________________________
Diagnoza: _________________________________________________________________________________
__________________________________________________________________________________________
Recomandări: _____________________________________________________________________________
Tratament _________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Examinări_________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Consultații_________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Vizita viitoare (data) ________________________________________________________________________
Semnătura și ștampila medicului de familie_____________________________________________________