FICHA GINECOLOGICANOMBRES Y APELLIDOS………………………………………………………………………………………………………EDAD………………………………………E.civil…………………………..NIVEL DE ESTUDIOS………………………………………………. TRABAJO ……………………. ESTABLE EVENTUAL

EVALUACION GINECOLOGICAFUR

URS

M

CICLOS REGULARES: SI NO

DISMENOREA SI NO

ITS SI NO

EMBARAZOS parto normal:

HIJOS vivos cesarea

hijos muertos

ABORTOS espontaneo Provocado

SEXUALIDAD

NECESITA INFORMACIONRELACIONES SEXUALES HETERO HOMO AMBAS

PAREJA UNICA VARIAS

EDAD INICIO RELACION SEXUAL AÑOS

PROBLEMAS EN RELACION SEXUAL NO SI

METODOS ANTICONCENTIVOS SIEMPRE A VECES NUNCA

CONDON SIEMPRE A VECES NUNCA

ABUSO SEXUAL SI NO

EXAMEN FISICO PESO IMC

TALLA

PIEL……………………………………………………………………………………………………………………………………………………………………………………………..

CABEZA……………………………………………………………………………………………………………………………………………………………………………………….

AGUDEZA VISUAL………………………………………………………………………………………………………………………………………………………………………

BOCA…………………………………………………………………………………………………………………………………………………………………………………………

TORAX………………………………………………………………………………………………………………………………………………………………………………………

MAMAS……………………………………………………………MAMOGRAFIA SI NO

P/A FC FR

ANTECEDENTES DE INFECIONES URINARIAS:……………………………………………………………………………………………………………………………

PAP SI NO

ALERGICA A ALGUN MEDICAMENTO:

antecedentes patologicos

anteceddentes quirurgicos………………………………………………………………………………….……………………………………………………………………………………………………………………………………………………………………………………………………………………………….……………………………………………………………………………………………………………….………………………………………………………………………………………………………………….……………………………………………………………………………………………………………….OBSERVACIONES………………………………………………………………………………………………………………………………………………………….……………………………………………………………………………………………………………………………………………………………………………………..……………………………………………………………………………………………………………………………………………………………………………………..…………………………………………………………………………………………………………………………………………………………………………………….……………………………………………………………………………………………………………………………………………………………………………………..…………………………………………………………………………………………………………………………………………………………………………………………………..……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

NOMBRES Y APELLIDOS………………………………………………………………………………………………………

PIEL……………………………………………………………………………………………………………………………………………………………………………………………..

CABEZA……………………………………………………………………………………………………………………………………………………………………………………….

AGUDEZA VISUAL………………………………………………………………………………………………………………………………………………………………………

BOCA…………………………………………………………………………………………………………………………………………………………………………………………

TORAX………………………………………………………………………………………………………………………………………………………………………………………

ANTECEDENTES DE INFECIONES URINARIAS:……………………………………………………………………………………………………………………………

OBSERVACIONES………………………………………………………………………………………………………………………………………………………….……………………………………………………………………………………………………………………………………………………………………………………..……………………………………………………………………………………………………………………………………………………………………………………..…………………………………………………………………………………………………………………………………………………………………………………….……………………………………………………………………………………………………………………………………………………………………………………..…………………………………………………………………………………………………………………………………………………………………………………………………..……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..