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Nombre

Contenido

1.- ANTECEDENTES PATOLOGICOS: $$
&nbsp;
DIABETES: $$
HIPERTENSION ARTERIAL: $$
TIROIDES:&nbsp; $$
CARDIOVASCULARES: $$
PULMONARES: $$
ALTERACIONES DE LA COAGULACION: $$
FAMILIARES: $$
CIRUGIAS PREVIAS: $$
&nbsp;
ALERGIAS: $$
&nbsp;
MEDICAMENTOS ACTUALES: $$
&nbsp;
TRANSFUSIONES: $$
&nbsp;
2.- ANTECEDENTES NO PATOLOGICOS:&nbsp;
&nbsp;
TABACO: $$
ALCOHOL: $$
OTROS: $$
3.- ANTECEDENTES GINECO-OBSTETRICOS:
&nbsp;
G: $$&nbsp; &nbsp; &nbsp; &nbsp;P: $$&nbsp; &nbsp; &nbsp; A: $$&nbsp; &nbsp; &nbsp; C: $$&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;FUM: $$ / $$ / $$&nbsp; &nbsp;&nbsp;
&nbsp;
Otros: $$&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;
&nbsp;
METODO ANTICONCEPTIVO: $$&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;
&nbsp;
4.- EXAMEN FISICO: $$
&nbsp;
AREA AFECTADA: $$
5.- PLAN QUIRURGICO: $$
&nbsp;
6.- PROCEDIMIENTO: $$

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