MF-2/2000

MEXICAN INSTITUTE OF SOCIAL SECURITY SOCIAL SECURITY NUMBER ADDED

MEDICAL BENEFITS MANAGEMENT

PATIENT'S NAME

MEDICAL HISTORY
PATERNO MATERNA NAME(S)
L

11 1 1 1 1 1 1 1 1
SECURITY AND SOCIAL
SOLIDARITY CU

UNIT OF ASSIGNMENT
REPORTER: Patient ( Anot
her No. CONSULTING SHIFT
SEX Male Female ( )

HEREDITARY AND FAMILIAL: RELATIONSHI TYPE OF FAMILY: NUCLEAR EXTENSA ( ) COMPOSITE

P

DIABETES MELLITUS YES

( ) NO
( ) ROLE OF THE
MOTHER:
E-M E-C E-S

FAMILY MEMBER RESPONSIBLE FOR

ARTERIAL HYPERTENSION YES
( ) NO
( ) THE PATIENT
FAMILY FAMILY DYSFUNCTIONS YE NO
ISCHEMIC CARDIOPATHY YES
( ) NO
( ) S

CANCER YES ( ) NO ( )
OTHER
PERSONAL NON-PATHOLOGICAL:

PLACE AND DATE OF BIRTH OCCUPATIO

EDO CIVIL SCHOLARSHIP TIME IN THE
N OCCUPATION

RELIGION FOOD BUSINESS ACTIVITY

PERSONAL HYGIENE PHYSICAL ACTIVITY

TYPE
PERSONAL PATHOLOGIES:

MEDICAL, SURGICAL, TRANSFUSION, SMOKING, ALCOHOLISM, ALLERGIES, DEPENDENCE ON DRUGS OR MEDICATIONS, OTHERS

MENARK
GYNECOBSTETRICS 1 1 year Start active sex life years Date of last menstrual period
GYNECOBSTETRICS:

1
No. of pregnancies í ) Date of last delivery 1 1 No. Couples: 1 1 IUD • 1
Childbirth 1___________11
No. of Sons 1___________1 Straight Hormonal

Abortions 1___________11 Live macrosomics Homosexuals Surgical 1___________1

Family Planning
method and time of
Cesarean sections 1___________11 Low birth weight Bisexuals use Another

CURRENT CONDITION:

DEVICES AND SYSTEMS:

PREVIOUS DIAGNOSTIC AIDS:

PREVIOUS MANAGEMENT AND TREATMENT:

ROOM OCCUPATIONAL RISK FACTORS

320 001 6438 01 01 ANV

 STATURE ACTUAL / IDEAL WEIGHT I.M.C TEMPERATURE BLOOD PRESSURE FREQUENCY

CARDIAC RESPIRATORY

GENERAL INSPECTION

HEAD

NECK

TORAX

ABDOMEN

SPINAL COLUMN

EXTERNAL GENITALIA

INTERNAL GENITALIA

EXTREMITIES

DIAGNOSIS

INTEGRATED TREATMENT AND MANAGEMENT

FORECAST

DATE OF PREPARATION PHYSICIAN'S NAME, REGISTRATION AND SIGNATURE

DIA MES YEAR