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MEDICAL HISTORY
ECTOSCOPIA
a) Name:______________________________________________________
b) Age: ________________________________________________________
c) Date of birth: ________________________________________________
d) Gender: _____________________________________________________
e) Race: _______________________________________________________
f) Nationality: __________________________________________________
g) Marital status:_______________________________________________
h) Occupation:__________________________________________________
i) Level studies: ________________________________________________
j) Birth Place: __________________________________________________
k) Hometown:__________________________________________________
l) Admission date: ______________________________________________
m) Referral: ____________________________________________________
CURRENT DISEASE
Disease Onset: ________________________________________
How it starts:
a) Insidious
b) Progressive
c)Acute
a) Headache
b) Stomachache
c) Runny nose
d) Fever ___
e) Others: _______
Chronological description:
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________
Appetite:____________________
Thirst: ______________________
Urine: _______________________
Feces: _______________________
Change in weight:_____________
Basal state: __________________
PHYSICAL EXAMINATION
Vital signs:
Blood pressure
Heart rate
Respiration rate
Temperature
Weight
Height
Body mass index
Oxygen saturation
Inspiratory fraction
PERSONAL HISTORY:
A. NOT PATHOLOGY
Socioeconomic Aspect :
1) lifestyle
a) High
b) Low
c) Medium
Immunizations vaccine :
a) Hepatitis A
b) Hepatitis B
c) Hepatitis C
d) Influenza
e) Cholera
f) Rubeolla
g) Tetano and Diphtheria
h) Yellow fever
i) Papiloma Virus
j) other
Grandmother
Aunts
Grandfather
Uncler
Mother
Diabetes
Arterial
Hipertension
Cncer
Father
Sister
Brother
Dislipidemia
Coronary
Heart
Disease
Asthma
Epilepsy
Stroke
Obesity
Arthritis
Liver disease
Lung disease
Early death
B. PATHOLOGICAL
Previous Illnesses:
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Y
N
Endocrinology
Type I Diabetes (Insulin dependant)
Type II Diabetes (Non-Insulin dependant)
Hyperthyroid
Hypothyroid
Goiter
Graves Disease
Neurological
Seizures
Epilepsy
Skin
Dermatitis
Rashes
Open sores
Psoriasis
Hematology
Blood clots from an injury or accident
Anemia
DVT (Deep Vein Thrombosis/Active Thrombophlebitis in legs)
Thrombocytopenia low platelets; bleeding problems
Iron supplements
Hemophilia
OB/GYN
Hormone replacement
Birth Control Pill/Patch
Irregular periods
Difficulty in conceiving
Gastrointestinal
GERD
Heartburn
Stomach (peptic ulcer)
Duodenal ulcer
Constipation
Diarrhea
Vomiting
Colitis
Irritable Bowel Syndrome
Crohns Disease
Gallbladder Disease
Gallstones (Cholelithiasis)
Inflammation/infection of gallbladder (Cholecystitis)
Respiratory
Asthma
Chronic Bronchitis
Sleep Apnea
Heaviness in chest
Congestive heart failure
Peripheral vascular disease
High cholesterol
Infectious Disease
Hepatitis A
Hepatitis B
Hepatitis C
HIV Positive
Liver Disease
Genital-Urinary
Recurrent urinary infection
Kidney stones
Kidney disease
Renal/Kidney failure (dialysis)
Gout
Stress incontinence
Musculoskeletal
Arthritis
Back pain
Migraine headaches (describe): ____________________________
Pain in weight bearing joints
Psychological
Depression: Medication: _____________________________________
Bi-Polar Disorder
Anxiety
Suicide attempt
Anorexia
Bulimia
Cancer
Lung
Breast
Prostate
Colon
Lymphoma
Other:____________________________________________________
Accidents and sequelae:
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Surgical:
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