Professional Documents
Culture Documents
AFILIACIN
Nombre completo______________________________________________________________
Edad _______________________fecha de nacimiento_______________________________
Sexo_________________________ Direccin ________________________________________
Datos obtenidos de__________________________Confiabilidad_________________________
MOTIVO DE CONSULTA
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
ANTECEDENTES FAMILIARES
Nombre completo madre_______________________________________________________
Edad Hbitos
Grupo sanguneo
G P C A
Gineco-obstetricos_____________________________________________________________
_____________________________________________________________________________
Ant. Patolgicos________________________________________________________________
_____________________________________________________________________________
Otros_familiares________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
EXAMEN FISICO
EXAMEN FISICO GENERAL
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
FC FR T PA
PESO TALLA IMC
ojos__________________________________________________________________________
orejas________________________________________________________________________
nariz_________________________________________________________________________
Boca_________________________________________________________________________
_____________________________________________________________________________
Cuello________________________________________________________________________
_____________________________________________________________________________
Torax_________________________________________________________________________
_____________________________________________________________________________
Corazn_______________________________________________________________________
____________________________________________________________________________
Pulmones_____________________________________________________________________
_____________________________________________________________________________
Abdomen_____________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Extremidades _________________________________________________________________
_____________________________________________________________________________
Genitourinario_________________________________________________________________
_____________________________________________________________________________
Neurolgico___________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
DIAGNOSTICO PRESUNTIVO
1. _______________________________________________________________________
2. _______________________________________________________________________
3. _______________________________________________________________________
4. _______________________________________________________________________
5. _______________________________________________________________________
MOTIVO DE CONSULTA
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
ANTECEDENTES PERINATALES
Producto de embarazo N_____________ de ________________ semanas de gestacin
Sitio de nacimiento _________________________________________________________
Tipo de Parto Vaginal / Cesrea por que________________________________________
Datos al nacimiento: Peso ____________ Talla_____________ PC___________________
APGAR_____________________________
Problemas al nacimiento_________________________________________________________
_____________________________________________________________________________
ANTECEDENTES FAMILIARES
Nombre completo madre_______________________________________________________
Edad Hbitos
Grupo sanguneo
G P C A
Gineco-obstetricos_____________________________________________________________
_____________________________________________________________________________
Ant. Patolgicos________________________________________________________________
_____________________________________________________________________________
Otros_familiares________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
EXAMEN FISICO
EXAMEN FISICO GENERAL
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
FC FR T PA
PESO TALLA IMC
orejas________________________________________________________________________
nariz_________________________________________________________________________
Boca_________________________________________________________________________
_____________________________________________________________________________
Cuello________________________________________________________________________
_____________________________________________________________________________
Torax_________________________________________________________________________
_____________________________________________________________________________
Corazn_______________________________________________________________________
____________________________________________________________________________
Pulmones_____________________________________________________________________
_____________________________________________________________________________
Abdomen_____________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Extremidades _________________________________________________________________
_____________________________________________________________________________
Genitourinario_________________________________________________________________
_____________________________________________________________________________
Neurolgico___________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
DIAGNOSTICO PRESUNTIVO
1. _______________________________________________________________________
2. _______________________________________________________________________
3. _______________________________________________________________________
4. _______________________________________________________________________
5. _______________________________________________________________________
AFILIACIN
Nombre completo______________________________________________________________
Edad _______________________fecha de nacimiento_______________________________
Sexo_________________________ Direccin ________________________________________
Datos obtenidos de__________________________Confiabilidad_________________________
MOTIVO DE CONSULTA
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
ANTECEDENTES PERINATALES
Producto de embarazo N_____________ de ________________ semanas de gestacin
Sitio de nacimiento _________________________________________________________
Tipo de Parto Vaginal / Cesrea por que________________________________________
Datos al nacimiento: Peso ____________ Talla_____________ PC___________________
APGAR_____________________________
Problemas al nacimiento_________________________________________________________
_____________________________________________________________________________
ANTECEDENTES FAMILIARES
Nombre completo madre_______________________________________________________
Edad Hbitos
Grupo sanguneo
G P C A
Gineco-obstetricos_____________________________________________________________
_____________________________________________________________________________
Ant. Patolgicos________________________________________________________________
_____________________________________________________________________________
Otros_familiares________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
EXAMEN FISICO
EXAMEN FISICO GENERAL
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
FC FR T PA
PESO TALLA IMC
ojos__________________________________________________________________________
orejas________________________________________________________________________
nariz_________________________________________________________________________
Boca_________________________________________________________________________
_____________________________________________________________________________
Cuello________________________________________________________________________
_____________________________________________________________________________
Torax_________________________________________________________________________
_____________________________________________________________________________
Corazn_______________________________________________________________________
____________________________________________________________________________
Pulmones_____________________________________________________________________
_____________________________________________________________________________
Abdomen_____________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Extremidades _________________________________________________________________
_____________________________________________________________________________
Genitourinario_________________________________________________________________
_____________________________________________________________________________
Neurolgico___________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
DIAGNOSTICO PRESUNTIVO
1. _______________________________________________________________________
2. _______________________________________________________________________
3. _______________________________________________________________________
4. _______________________________________________________________________
5. _______________________________________________________________________
AFILIACIN
Nombre completo______________________________________________________________
Edad _______________________fecha de nacimiento_______________________________
Sexo_________________________ Direccin ________________________________________
Datos obtenidos de__________________________Confiabilidad_________________________
MOTIVO DE CONSULTA
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
ANTECEDENTES PERINATALES
Producto de embarazo N_____________ de ________________ semanas de gestacin
Sitio de nacimiento _________________________________________________________
Tipo de Parto Vaginal / Cesrea por que________________________________________
Datos al nacimiento: Peso ____________ Talla_____________ PC___________________
APGAR_____________________________
Problemas al nacimiento_________________________________________________________
_____________________________________________________________________________
ANTECEDENTES FAMILIARES
Nombre completo madre_______________________________________________________
Edad Hbitos
Grupo sanguneo
G P C A
Gineco-obstetricos_____________________________________________________________
_____________________________________________________________________________
Ant. Patolgicos________________________________________________________________
_____________________________________________________________________________
Otros_familiares________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
EXAMEN FISICO
EXAMEN FISICO GENERAL
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
FC FR T PA
PESO TALLA IMC
ojos__________________________________________________________________________
orejas________________________________________________________________________
nariz_________________________________________________________________________
Boca_________________________________________________________________________
_____________________________________________________________________________
Cuello________________________________________________________________________
_____________________________________________________________________________
Torax_________________________________________________________________________
_____________________________________________________________________________
Corazn_______________________________________________________________________
____________________________________________________________________________
Pulmones_____________________________________________________________________
_____________________________________________________________________________
Abdomen_____________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Extremidades _________________________________________________________________
_____________________________________________________________________________
Genitourinario_________________________________________________________________
_____________________________________________________________________________
Neurolgico___________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
DIAGNOSTICO PRESUNTIVO
1. _______________________________________________________________________
2. _______________________________________________________________________
3. _______________________________________________________________________
4. _______________________________________________________________________
5. _______________________________________________________________________
AFILIACIN
Nombre completo______________________________________________________________
Edad _______________________fecha de nacimiento_______________________________
Sexo_________________________ Direccin ________________________________________
Datos obtenidos de__________________________Confiabilidad_________________________
MOTIVO DE CONSULTA
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
ANTECEDENTES PERINATALES
Producto de embarazo N_____________ de ________________ semanas de gestacin
Sitio de nacimiento _________________________________________________________
Tipo de Parto Vaginal / Cesrea por que________________________________________
Datos al nacimiento: Peso ____________ Talla_____________ PC___________________
APGAR_____________________________
Problemas al nacimiento_________________________________________________________
_____________________________________________________________________________
ANTECEDENTES FAMILIARES
Nombre completo madre_______________________________________________________
Edad Hbitos
Grupo sanguneo
G P C A
Gineco-obstetricos_____________________________________________________________
_____________________________________________________________________________
Ant. Patolgicos________________________________________________________________
_____________________________________________________________________________
Otros_familiares________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
EXAMEN FISICO
EXAMEN FISICO GENERAL
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
FC FR T PA
PESO TALLA IMC
ojos__________________________________________________________________________
orejas________________________________________________________________________
nariz_________________________________________________________________________
Boca_________________________________________________________________________
_____________________________________________________________________________
Cuello________________________________________________________________________
_____________________________________________________________________________
Torax_________________________________________________________________________
_____________________________________________________________________________
Corazn_______________________________________________________________________
____________________________________________________________________________
Pulmones_____________________________________________________________________
_____________________________________________________________________________
Abdomen_____________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Extremidades _________________________________________________________________
_____________________________________________________________________________
Genitourinario_________________________________________________________________
_____________________________________________________________________________
Neurolgico___________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
DIAGNOSTICO PRESUNTIVO
1. _______________________________________________________________________
2. _______________________________________________________________________
3. _______________________________________________________________________
4. _______________________________________________________________________
5. _______________________________________________________________________