Professional Documents
Culture Documents
Fecha:
Mdico: ________________________________.
DATOS PERSONALES
Apellido y Nombre: _________________________________________________________________________.
Sexo: _____. Edad: ______. Estado Civil: _______________. Ocupacin: ____________________________.
Domicilio: _____________________________________________________________. TE: ______________.
Residencia: _______________________________________________________________________________ .
MOTIVO DE CONSULTA
ANAMNESIS SISTEMICA
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ANTECEDENTES PERSONALES
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2- Inmunizaciones.
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3- Vivienda y medio ambiente.
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4- Socioeconmicos.
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5- Patolgicos: mdicos, alrgicos, ____________________________________________________________
quirrgicos, traumticos.
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6-Txico-Medicamentosos: tabaco, ____________________________________________________________
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alcohol, drogas ilcitas,
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medicamentos, otros.
1-Fisiolgicos : menarca, ciclo
menstrual, fecha ltima
menstruacin, embarazos, partos,
alimentacin, actividad fsica,
sueo, diuresis y catarsis, actividad
sexual, otros.
7-Epidemiologcos:Chagas,
HIV/Sida, Brucelosis,
Toxoplasmosis, transfusiones,
residencias anteriores, otros.
8-Heredo-Familiares.
9- Otros.
1-Inspeccin General
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EXAMEN FISICO
Examen General
Actitud: _____________________________________________________.
Decbito:
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Marcha:
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Facie:
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Estado de conciencia: __________________________________________.
2-Mediciones y Controles
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Examen Segmentario
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LISTADO DE PROBLEMAS
LISTADO DE DIAGNOSTICOS
TRATAMIENTO INICIAL
EVOLUCIONES
EPICRISIS