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PATIENT'S NAME
MEDICAL HISTORY
PATERNO MATERNA NAME(S)
L
11 1 1 1 1 1 1 1 1
SECURITY AND SOCIAL
SOLIDARITY CU
UNIT OF ASSIGNMENT
REPORTER: Patient ( Anot
her No. CONSULTING SHIFT
SEX Male Female ( )
CANCER YES ( ) NO ( )
OTHER
PERSONAL NON-PATHOLOGICAL:
TYPE
PERSONAL PATHOLOGIES:
MEDICAL, SURGICAL, TRANSFUSION, SMOKING, ALCOHOLISM, ALLERGIES, DEPENDENCE ON DRUGS OR MEDICATIONS, OTHERS
MENARK
GYNECOBSTETRICS 1 1 year Start active sex life years Date of last menstrual period
GYNECOBSTETRICS:
1
No. of pregnancies í ) Date of last delivery 1 1 No. Couples: 1 1 IUD • 1
Childbirth 1___________11
No. of Sons 1___________1 Straight Hormonal
CURRENT CONDITION:
CARDIAC RESPIRATORY
GENERAL INSPECTION
HEAD
NECK
TORAX
ABDOMEN
SPINAL COLUMN
EXTERNAL GENITALIA
INTERNAL GENITALIA
EXTREMITIES
DIAGNOSIS
FORECAST