ESTABLISHMENT NAME LAST NAME SEX (M-F) SHEET NO. MEDICAL HISTORY NO.

1 REASON FOR CONSULTATION NOTE THE CAUSE OF THE PROBLEM IN THE INFORMANT'S VERSION OF
THE PROBLEM

A C

B D

DESCRIBE BELOW, WITH THE

2 PERSONAL BACKGROUND RESPECTIVE NUMBER
FUM= DATE OF LAST MENSTRUAL PERIOD FUP= DATE OF LAST DELIVERY FUC= DATE OF LAST CYTOLOGY

1. 5. ENF. 9. ENF. 13. ENF. 17. SEXUAL 21. PHYSICAL MENARCHY MENOPAUSE
CYCLES ACTIVE SEX LIFE
VACCINES ALLERGIC NEUROLOGICAL TRAUMATOL. TENDENCY ACTIVITY -EDAD- -EDAD-

2. ENF. 10. ENF. 14. ENF. CHILDREN

6. ENF. CARDIAC 18. SOCIAL RISK 22. DIET AND HABITS GESTA PARTS ABORTIONS CESAREAS
PERINATAL METABOLIC SURGERY VIVOS

3. ENF. 7. ENF. 11. ENF. HEMO 15. ENF. 19. OCCUPATIONAL RELIGION AND
FUM FUP FUC BIOPSY
INFANCY RESPIRATORY LINF. MENTAL HAZARD CULTURE

4. ENF. 8. ENF. 12. ENF. 16. ENF. T. METHOD OF P. COLPOS

20. FAMILY RISK OTHER HORMONE THERAPY MAMO GRAPHY
DIGESTIVE ADOLESCENT URINARIA SEXUAL FAMILIAR COPIA

3 FAMILY HISTORY DESCRIBE BELOW NOTING THE NUMBER.

1. 3. ENF. C. 4. HYPER 6.TUBERCULO 8. ENF.

2. DIABETES 5. CANCER 7. ENF. MENTAL 9. BAD TRAINING 10. OTHER
CARDIOPATHY VASCULAR TENSION SIS INFECTIOUS

CHRONOLOGY, LOCATION, CHARACTERISTICS, INTENSITY, APPARENT CAUSE, AGGRAVATING

4 CURRENT ILLNESS OR PROBLEM OR AMELIORATING FACTORS, ASSOCIATED SYMPTOMS, EVOLUTION, MEDICATIONS RECEIVED,
RESULTS OF PREVIOUS EXAMINATIONS, CURRENT CONDITION

CP = WITH EVIDENCE OF PATHOLOGY: MARK "X" Y

SP = NO EVIDENCE OF PATHOLOGY:
5 CURRENT REVIEW OF ORGANS AND SYSTEMS DESCRIBE BELOW NOTING THE NUMBER AND LETTER
CP SP CP SP CP SP CP SP CP SP
ORGANS OF THE MUSCLE
1
SENSES 3 CARDIO VASCULAR 5 GENITAL 7
SKELETAL 9 LYMPHATIC HEME

2 RESPIRATORY 4 DIGESTIVE 6 URINARY 8 ENDOCRINE 10 NERVOUS

SNS-MSP / HCU-form.003 / 2008 ANAMNESIS

SNS-MSP / HCU-form.003 / 2008 ANAMNESIS
 6 VITAL SIGNS AND MEASUREMENTS
/
ORAL CEPHALIC
BLOOD FREQUENCY FREQUENCY TEMPERATURE WEIGHT SIZE
TEMPERATURE PERIMETER
PRESSURE CARDIAC min BREATHE. min AXILAR °C Kg m cm
°C

7 PHYSICAL R= REGIONAL S=
SYSTEMIC
CP = WITH EVIDENCE OF PATHOLOGY: MARK "X" AND DESCRIBE BELOW
NOTING THE CORRESPONDING NUMBER AND LETTER.
SP = NO EVIDENCE OF PATHOLOGY:
MARK "X" AND DO NOT DESCRIBE
EXAMINATION CP SP
SENSE ORGANS
1-R SKIN - FLANKS 6-R BOCA 11-R ABDOMEN 1-S 6-S URINARY

COLUMN SKELETAL
2-R HEAD 7-R FARINGE GOLD 12-R 2-S RESPIRATORY 7-S MUSCLE
VERTEBRAL

3-R EYES 8-R NECK 13-R INGLE-PERINÉ 3-S CARDIO VASCULAR 8-S ENDOCRINE

EARS UPPER LIMBS LYMPHATIC HEMO

4-R 9-R AXILAS - BREASTS 14--R 4-S DIGESTIVE 9-S

THORAX LOWER LIMBS NEUROLOGICAL

5-R NOSE 10-R 15--R 5-S GENITAL 10-S

DIAGNOSIS PRE= PRESUMPTIVE

DEF= FINAL
CIE PRE DEF CIE PRE DEF

1 4

2 5

3 6

9 TREATMENT PLANS DIAGNOSTIC, THERAPEUTIC AND EDUCATIONAL

CODE

NAME OF SHEET
DATE TIME SIGNATURE
PROFESSIONAL NUMBER
SNS-MSP / HCU-form.003 / 2008 EXAMINATION
SNS-MSP / HCU-form.003 / 2008 EXAMINATION