IDENTIFICATION SHEET
Name: Sex: Age:
Marital status: Occupation:
Place of origin: Date of Birth:
Residence (dir. and tel.)
Place and date:
INHERITED FAMILY BACKGROUND: DESCRIPTION Neoplasms: denied
Syphilis:
Tuberculosis: Heart:
Vascular:
Obesity:
Diabetes:
Arthritis:
Mental or nervous diseases:
PERSONAL HISTORY nonpathological
Food: Number of meals, amount, dairy, meats, fruits. vegetables, legumes, junk food, Quality
Hours: Breakfast, Lunch, Dinner.
Room that sleeps in, Apartment, Aeration
Lighting, Overcrowding. Promiscuity. Defecation.
Water. Drainage. Environment
3 .- Hygiene Habits
4 .- Addiction.
5 .- occupied.
6 .- schooling.
Medical history
DESCRIBE THE POSITIVE:
1 .- Measles, Varicella, Rubella, Mumps, Meningitis, Poliomyelitis:
2 .- Syphilis, gonorrhea, chancroid, chancre hard ridges, Genital Warts:
3 .- Tuberculosis: 4 .- Malaria:
5 .- Typhoid and other salmonella:
6 .- Malta Fever:
7 .- Infectious hepatitis:
8 .- Otitis:
9 .- Tonsillitis:
10 .- Rheumatic fever Care:
11 .- Parasites, amoebic would disagree:
12 .- Diabetes Mellitus:
13 .- Allergies:
14 .- Neurological and Psychiatric:
15 .- Transfusions:
16 .- Immunizations:
17.-trauma, mutilation and operations:
Current condition:
Describe it according to the guidelines given below, with fluent language, understandable, in that order.
Notions of time (start date)
Site Concept, cause. c: rcuiístancia
Cardinal symptoms in chronological order
Developments to date
If several conditions co-exist, write on the table first deemed the most important
DESCRIPTION:
DEVICES AND SYSTEMS
DIGESTIVE
1 .- Appetite, taste, breath, salivation, dry mouth, sore mouth
2 .- chewing, swallowing, sore throat, dysphagia
3 .- belching, heartburn, regurgitation and heartburn
4 .- Nausea, vomiting, hematemesis and melena
5 .- equivalents abdominal pain
6 .- Bloating, rumbling, bloating, indigestion 7 .- normal evacuation. Constipation, diarrhea
8.-Characteristics of the stool (melena, fresh blood, mucus, pus, parasites, thinning of the stool)
9 .- itching, burning, anal, blood or pus in lingerie 10 .- rectal pain, straining, urgency
11 .- Colic liver, pancreatic pain
12 .- jaundice, dark urine, acolia. Steatorrhea
DESCRIBE THE POSITIVE:
RESPIRATORY:
1 .- Rhinorrhea, epistaxis, burning, pain and nasal itching
2 .- Permeability nasopharyngeal
3 .- Dysphonia
4 .- Pain, burning, itching, tightness retrosternal
5 .- audible crackles
6 .- chest pain
7 .- Cough characters
8 .- hemoptysis, cyanosis
Describe the positive:
CIRCULATORY
1 .- Dyspnea (of effort, decubitus or paroxysmal)
2 .- precordial palpitations (associated or not the effort) 3 .- Chest pain
4 .- Edema (time, site extension)
5 .- acroparesthesias, photopsia, transient tinnitus, dizziness 6 .- Headache, cranial tightness
7 .- Intermittent claudication
Describe the positive:
Hemopoietic APPARATUS
Bleeding tendency: epistaxis, petechiae, menorrhagia, melena, hematuria, excessive bleeding after a tooth is removed.
Manifestations of anemia: fatigue, weakness, shortness of breath, fainting by position changes, headache, fainting, tachycardia, hypotension, loss of consciousness, restlessness, thirst, dyspnea, sweating, fever and irritability. Signs of shock: hypotension, hypesthesia and hypothermia.
Polycythemia: headache, dizziness, tinnitus, dizziness, blurred vision, cyanosis. Leukopenia: mouth sores.
Manifestation of infection: fever, chills, myalgia, photophobia, dehydration.
Manifestations of leukemia: anemia, bleeding, lymphadenopathy, splenomegaly and hepatomegaly, anorexia, weight loss and fever. Describe the positive:
Endocrine system:
Adenohypophysis: acromegaly, gigantism, dwarfism, early or late puberty, glactorrea, impotence, female frigidity, gnecomastia, polydipsia and polyuria.
Thyroid tumors in the neck, fistula / as at the base of the tongue, unilateral or bilateral exophthalmos, neck pain, odynophagia, dysphagia, hoarseness, tachycardia, increased temperature, nervousness, irritability, sweating palms of hands, Perida weight, slow response and growth in thinking, fatigue easily.
Parathyroid muscle spasms, tetany, kidney stones, hoarseness, transient paresis, peptic ulcer.
Adrenal: amenorrhea, or hirsutisrno virilism, edema, moon face, buffalo hump, manifest changes in pigmentation of the skin and mucous membranes, obesity, osteoporosis, menstrual disorders. Pancreas: polyphagia, polydipsia, polyuria
Describe the positive:
NUTRITION
Thirst, muscle weakness, edema, growth failure, anemia, bleeding disorders, depression, diarrhea, anorexia, paresthesia, fatigue, muscle pain, tremors, dental caries.
DESCRIBE THE POSITIVE
Rheumatologist SYSTEM
Morning stiffness, arthralgia, pain on movement. Joint swelling, subcutaneous nodules, muscle weakness, redness of a joint, fever. '
BI R Descri POSITIVE:
WOMEN'S GENITAL
Characters Menarche Menstruation: rhythm:
Duration: quantity: pain:
Number of pregnancies: Births, Abortions:
Cesarean: Premature Births: Stillbirths:
Number of live births products: dystocia:
Multiple pregnancy: toxemia of pregnancy:
Attention of their births:
Premenstrual tension:
Amenorrhea Oligomenorrhea: hypomenorrhea: Menorrhagia: Polymenorrhea: Leucorrhoea:
Libido: normal:
Genital pain. Semiology
Mammary gland: pain
Secretions: Tumors: Eruptions: Galactorrhea: Edema:
Menopause: Metrorrhagia: Menopause:
MAN GENITAL
Libido, erection, ejaculation, Spermatorrhoea:
Heterosexuality, Homosexuality, Bisexuality: Congenital anomalies:
Genital pain semiology:
URINARY
Diuresis in 24 hours:
Urination:
Urine: characters: clear cloudy, with blood: for: with grit: another color: pain:
Edema. Semiology:
Expulsion of calculations:
Musculoskeletal system
Bone, muscle and joint, site, radiation, intensity, duration, location, probable causative agents, circumstances in which they appear and quality of pain.
Bone and joint range of motion:
Abnormal bone and joint movements:
PERIPHERAL NERVOUS SYSTEM CENTRAL
Mobility: voluntary, involuntary. Paralysis, paresis, tremors.
Sensitivity: Superficial anesthesia, hyperesthesia, hypoesthesia, dysesthesia, paresthesia, Algier. Profound: muscle, bone, joint and proprioception.
Neurovegetative Oistonías sweating, irritability, mood swings.
DESCRIBE THE POSITIVE
SENSE ORGANS
View: dismetropía, amaurosis, diplopia, scotomata, persistent fotósfenos Smell: anosmia, cacosmia:
Hearing: anacusias, hearing loss, tinnitus persistent unilateral or bilateral tinnitus
Ear: vertigo, balance disorders:
Taste: determnar flavors: sweet, bitter, sour, salty, alkaline taste changes:
STATE PSYCHIATRIC-Reply
State, psychic-somatic, psychic personality, sleep, excitability, depression, anxiety, memory, adaptation, fear, anger, indifference, passion, anxiety, calm, concern, sadness, moodiness, good humor, laughter, pessimistic, optimistic, forgetfulness, hatred, empathy and self-control.
GENERAL SYMPTOMS
Chill, grief, chills, GC, sweating, changes in the
Kg weight, fatigue, weakness, sweating and dehydration. _
THERAPY USED
Home Remedies:
Drugs: what:
Surgical: name
Examinations
Laboratory analysis
Cabinet:
Name: Sex: Age:
Marital status: Occupation:
Place of origin: Date of Birth:
Residence (dir. and tel.)
Place and date:
INHERITED FAMILY BACKGROUND: DESCRIPTION Neoplasms: denied
Syphilis:
Tuberculosis: Heart:
Vascular:
Obesity:
Diabetes:
Arthritis:
Mental or nervous diseases:
PERSONAL HISTORY nonpathological
Food: Number of meals, amount, dairy, meats, fruits. vegetables, legumes, junk food, Quality
Hours: Breakfast, Lunch, Dinner.
Room that sleeps in, Apartment, Aeration
Lighting, Overcrowding. Promiscuity. Defecation.
Water. Drainage. Environment
3 .- Hygiene Habits
4 .- Addiction.
5 .- occupied.
6 .- schooling.
Medical history
DESCRIBE THE POSITIVE:
1 .- Measles, Varicella, Rubella, Mumps, Meningitis, Poliomyelitis:
2 .- Syphilis, gonorrhea, chancroid, chancre hard ridges, Genital Warts:
3 .- Tuberculosis: 4 .- Malaria:
5 .- Typhoid and other salmonella:
6 .- Malta Fever:
7 .- Infectious hepatitis:
8 .- Otitis:
9 .- Tonsillitis:
10 .- Rheumatic fever Care:
11 .- Parasites, amoebic would disagree:
12 .- Diabetes Mellitus:
13 .- Allergies:
14 .- Neurological and Psychiatric:
15 .- Transfusions:
16 .- Immunizations:
17.-trauma, mutilation and operations:
Current condition:
Describe it according to the guidelines given below, with fluent language, understandable, in that order.
Notions of time (start date)
Site Concept, cause. c: rcuiístancia
Cardinal symptoms in chronological order
Developments to date
If several conditions co-exist, write on the table first deemed the most important
DESCRIPTION:
DEVICES AND SYSTEMS
DIGESTIVE
1 .- Appetite, taste, breath, salivation, dry mouth, sore mouth
2 .- chewing, swallowing, sore throat, dysphagia
3 .- belching, heartburn, regurgitation and heartburn
4 .- Nausea, vomiting, hematemesis and melena
5 .- equivalents abdominal pain
6 .- Bloating, rumbling, bloating, indigestion 7 .- normal evacuation. Constipation, diarrhea
8.-Characteristics of the stool (melena, fresh blood, mucus, pus, parasites, thinning of the stool)
9 .- itching, burning, anal, blood or pus in lingerie 10 .- rectal pain, straining, urgency
11 .- Colic liver, pancreatic pain
12 .- jaundice, dark urine, acolia. Steatorrhea
DESCRIBE THE POSITIVE:
RESPIRATORY:
1 .- Rhinorrhea, epistaxis, burning, pain and nasal itching
2 .- Permeability nasopharyngeal
3 .- Dysphonia
4 .- Pain, burning, itching, tightness retrosternal
5 .- audible crackles
6 .- chest pain
7 .- Cough characters
8 .- hemoptysis, cyanosis
Describe the positive:
CIRCULATORY
1 .- Dyspnea (of effort, decubitus or paroxysmal)
2 .- precordial palpitations (associated or not the effort) 3 .- Chest pain
4 .- Edema (time, site extension)
5 .- acroparesthesias, photopsia, transient tinnitus, dizziness 6 .- Headache, cranial tightness
7 .- Intermittent claudication
Describe the positive:
Hemopoietic APPARATUS
Bleeding tendency: epistaxis, petechiae, menorrhagia, melena, hematuria, excessive bleeding after a tooth is removed.
Manifestations of anemia: fatigue, weakness, shortness of breath, fainting by position changes, headache, fainting, tachycardia, hypotension, loss of consciousness, restlessness, thirst, dyspnea, sweating, fever and irritability. Signs of shock: hypotension, hypesthesia and hypothermia.
Polycythemia: headache, dizziness, tinnitus, dizziness, blurred vision, cyanosis. Leukopenia: mouth sores.
Manifestation of infection: fever, chills, myalgia, photophobia, dehydration.
Manifestations of leukemia: anemia, bleeding, lymphadenopathy, splenomegaly and hepatomegaly, anorexia, weight loss and fever. Describe the positive:
Endocrine system:
Adenohypophysis: acromegaly, gigantism, dwarfism, early or late puberty, glactorrea, impotence, female frigidity, gnecomastia, polydipsia and polyuria.
Thyroid tumors in the neck, fistula / as at the base of the tongue, unilateral or bilateral exophthalmos, neck pain, odynophagia, dysphagia, hoarseness, tachycardia, increased temperature, nervousness, irritability, sweating palms of hands, Perida weight, slow response and growth in thinking, fatigue easily.
Parathyroid muscle spasms, tetany, kidney stones, hoarseness, transient paresis, peptic ulcer.
Adrenal: amenorrhea, or hirsutisrno virilism, edema, moon face, buffalo hump, manifest changes in pigmentation of the skin and mucous membranes, obesity, osteoporosis, menstrual disorders. Pancreas: polyphagia, polydipsia, polyuria
Describe the positive:
NUTRITION
Thirst, muscle weakness, edema, growth failure, anemia, bleeding disorders, depression, diarrhea, anorexia, paresthesia, fatigue, muscle pain, tremors, dental caries.
DESCRIBE THE POSITIVE
Rheumatologist SYSTEM
Morning stiffness, arthralgia, pain on movement. Joint swelling, subcutaneous nodules, muscle weakness, redness of a joint, fever. '
BI R Descri POSITIVE:
WOMEN'S GENITAL
Characters Menarche Menstruation: rhythm:
Duration: quantity: pain:
Number of pregnancies: Births, Abortions:
Cesarean: Premature Births: Stillbirths:
Number of live births products: dystocia:
Multiple pregnancy: toxemia of pregnancy:
Attention of their births:
Premenstrual tension:
Amenorrhea Oligomenorrhea: hypomenorrhea: Menorrhagia: Polymenorrhea: Leucorrhoea:
Libido: normal:
Genital pain. Semiology
Mammary gland: pain
Secretions: Tumors: Eruptions: Galactorrhea: Edema:
Menopause: Metrorrhagia: Menopause:
MAN GENITAL
Libido, erection, ejaculation, Spermatorrhoea:
Heterosexuality, Homosexuality, Bisexuality: Congenital anomalies:
Genital pain semiology:
URINARY
Diuresis in 24 hours:
Urination:
Urine: characters: clear cloudy, with blood: for: with grit: another color: pain:
Edema. Semiology:
Expulsion of calculations:
Musculoskeletal system
Bone, muscle and joint, site, radiation, intensity, duration, location, probable causative agents, circumstances in which they appear and quality of pain.
Bone and joint range of motion:
Abnormal bone and joint movements:
PERIPHERAL NERVOUS SYSTEM CENTRAL
Mobility: voluntary, involuntary. Paralysis, paresis, tremors.
Sensitivity: Superficial anesthesia, hyperesthesia, hypoesthesia, dysesthesia, paresthesia, Algier. Profound: muscle, bone, joint and proprioception.
Neurovegetative Oistonías sweating, irritability, mood swings.
DESCRIBE THE POSITIVE
SENSE ORGANS
View: dismetropía, amaurosis, diplopia, scotomata, persistent fotósfenos Smell: anosmia, cacosmia:
Hearing: anacusias, hearing loss, tinnitus persistent unilateral or bilateral tinnitus
Ear: vertigo, balance disorders:
Taste: determnar flavors: sweet, bitter, sour, salty, alkaline taste changes:
STATE PSYCHIATRIC-Reply
State, psychic-somatic, psychic personality, sleep, excitability, depression, anxiety, memory, adaptation, fear, anger, indifference, passion, anxiety, calm, concern, sadness, moodiness, good humor, laughter, pessimistic, optimistic, forgetfulness, hatred, empathy and self-control.
GENERAL SYMPTOMS
Chill, grief, chills, GC, sweating, changes in the
Kg weight, fatigue, weakness, sweating and dehydration. _
THERAPY USED
Home Remedies:
Drugs: what:
Surgical: name
Examinations
Laboratory analysis
Cabinet:
Ok Lourdes
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