HISTORIA

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DE

SALUD DEL ADULTO No.

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ANAMNESIS GENERAL

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___________ Gnero:_________ Estado civil:__________ Escolaridad: _______________________
Lugar de nacimiento: _________________________ Procedencia: ________________________________
Religin: ________________________Institucin: _________________________________________
Afiliacin al SGSSS: __________________________________________________________________
Nombres:
Edad:

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Motivo de la consulta:

Situacin actual:

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Antecedentes Personales
Patolgicos:

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Gineco obsttricos: ____________________________________________________________________
Quirrgicos: ________________________________________________________________________
Traumticos: _______________________________________________________________________
Hospitalarios: _______________________________________________________________________
Inmunolgicos: ______________________________________________________________________
Psiquitricos:

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Farmacolgicos: ______________________________________________________________________
Txicos: ______________________________________________________________________________________________________
Antecedentes Familiares:

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Historia personal

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ANAMNESIS POR SISTEMAS

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EXAMEN FSICO

Peso__________________
Talla ________________
Relacin Cintura - Cadera: _____________________________________

I. M. C. ___________________________

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O.I. ______________________
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T: ______________________
Respiracin: _______________________________________________
Pulso: ___________________________________________________
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Agudeza Visual:

O.D.

Signos Vitales:

T.A.

EXAMEN MENTAL:

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VALORACION FAMILIAR

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VALORACION REDES SOCIALES DE APOYO

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Nombre del estudiante y cdigo

ltima revisin Agosto 16 de 2006

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Nombre del Docente y cdigo