1 de 2

EXMEN MDICO
FECHA_____DE________________DEL_________

FICHA DE IDENTIFICACIN
Nombre___________________________________________________ Sexo M_____F_____
Edad ______ Programa Educativo____________________________ Grupo_____________
Nmero de control_____________________________________________________________
Domicilio_____________________________________________________________________
Tipo sanguneo________________________________________________________________

ANTECEDENTES HEREDO-FAMILIARES
Diabetes: ____________________________________________________________________
Hipertensin: _________________________________________________________________
Cncer: _____________________________________________________________________
Otros: _______________________________________________________________________

ANTECEDENTES PERSONALES NO PATOLGICOS

Estado Civil: _______________________________.
Escolaridad: _________________
Tabaco: No___ Si___ aos: ____actual No___ Si___ Exposicin al humo: No___ Si___
Alcohol: No___ Si___ aos: ____actual No___ Si___
Drogas: No___ Si___ aos: ____actual No___ Si___
Deporte:
No___ Si___
Esquema de inmunizaciones: ___________________.
Alimentacin: B___ R___ M___
Vida Sexual Activa: No___ Si___ No. de parejas: ___ Mtodos anticonceptivos: ___________
Enfermedad de trasmisin sexual: No___ Si ___
Cul________________________________________________________________________

ANTECEDENTES GINECOOBSTETRICOS
Menarca ______ aos Ritmo_____/______ IVSA_______ aos
G______P______A_______C______
FUR________ FUP_________ Menopausia a los______ aos ltimo Papanicolaou_______
Mtodos de Planificacin Familiar:
No___ Si___
Cul________________________________________________________________________
Enfermedades de Transmisin Sexual: No___ Si___
Cul________________________________________________________________________

ANTECEDENTES PERSONALES PATOLGICOS

Quirrgicos:
No____ Si____
Cul________________________________________________________________________
Internamientos:
No____ Si____ Cundo_______________ Por qu_______________
Trasfusiones Previas: No____ Si____ Fecha______________________________________
Alergias:
No____ Si____ A que______________________________________
Fracturas:
No____ Si____ Cundo____________________________________

PADECIMIENTO ACTUAL (Motivo de la consulta)

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

Rev. 3: 28/octubre/2013

F-JSM-01

2 de 2
EXPLORACIN FSICA
CABEZA:_______________________________________________________________________
_________________________________________________________________________
AGUDEZA VISUAL: __________ Normal: _________________ Disminucin: ______________
____________________________________________________________________________
CORRECCIN:__________________________________________________________________
_________________________________________________________________________
PROBLEMA:____________________________________________________________________
_________________________________________________________________________
CARIES:
______________________________SARRO:_______________________________________
CUELLO:_______________________________________________________________________
_________________________________________________________________________
TORAX:________________________________________________________________________
_________________________________________________________________________
ABDDOMEN:____________________________________________________________________
_________________________________________________________________________
EXTREMIDADES:________________________________________________________________
_________________________________________________________________________
GENITALES:____________________________________________________________________
_________________________________________________________________________
T/A______/______
FC_________ /min.
FR_________/min.
T_________C
Peso______kg.
Estatura______mts.
DxTx__________mg/dl.

MEDICAMENTO ACTUAL
Medicamento_________________________________________________________________
Dosis_______________________________________________________________________
Tiempo de ingerirlo____________________________________________________________

DIAGNSTICOS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
______________________________________________________
ANLISIS DEL CASO Y COMENTARIOS
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
______________________________________________________
REALIZ: ___________________________________________________________________

CDULA: ___________________________ RSS: ___________________________

___________________________
FIRMA

Rev. 3: 28/octubre/2013

F-JSM-01