I. DATOS PERSONALES
• Patológicos: ________________________________________________________________________________
• Quirúrgicos: _______________________________________________________________________________
• Alérgicos: __________________________________________________________________________________
• Transfusionales: ____________________________________________________________________________
• Ginecobstétricos:
FUM: ____________ G___P___C___A___ Anticonceptivos: ________________
Fecha de última citología: ___________________
V. ANTECEDENTES FAMILIARES
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• Signos vitales
TA: _____________ FC: _______ FR: ______ T°: ______ Peso: _______ Talla: ________
• Apariencia General: _________________________________________________________________________
• Cabeza: ___________________________________________________________________________________
• Cuello : ____________________________________________________________________________________
• Órganos De Los Sentidos: ____________________________________________________________________
• Cardiopulmonar: ___________________________________________________________________________
• Abdomen:__________________________________________________________________________________
• Genitourinario: _____________________________________________________________________________
• Extremidades: ______________________________________________________________________________
• Piel Y Faneras: _____________________________________________________________________________
• Sistema Nervioso: ___________________________________________________________________________
1.__________________________________________________________
2.__________________________________________________________
3.__________________________________________________________
4.__________________________________________________________
XI. PLAN
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R.M.
EVOLUCIÓN
DATOS PERSONALES