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|COMANDO GENERAL DE LAS FUERZAS MILITARES

DIRECCION GENERAL DE SANIDAD MILITAR


HISTORIA ODONTOLOGICA

No. HISTORIA CLINICA


Ciudad y Fecha: _________________________________________
I.

DATOS PERSONALES

NOMBRE Y APELLIDOS:
TIPO DOCUMENTO:

No:

GRADO

UNIDAD

FECHA DE NACIMIENTO

EDAD

SEXO

ESTADO CIVIL

OCUPACION

No. TELEFONO

DIRECCION

No. CELULAR

NOMBRE ACUDIENTE

II.

RELACION CON EL PACIENTE

TELEFONO

MOTIVO DE CONSULTA
_________________________________________________________________________

______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
III.

ENFERMEDAD ACTUAL
_________________________________________________________________________

______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
IV.

ANTECEDENTES PERSONALES
SI

NO

OBSERVACIONES

SISTEMA NERVIOSO

______________________________________________________

SISTEMA RESPIRATORIO

______________________________________________________

DIABETES

______________________________________________________

HEPATITIS

______________________________________________________

FIEBRE REUMATICA

______________________________________________________

ACCIDENTES/TRAUMAS

______________________________________________________

HOSPITALIZACIONES

______________________________________________________

CIRUGIAS

______________________________________________________

ALERGIAS

______________________________________________________

S. CARDIOVASCULAR

______________________________________________________

COAGULACION

______________________________________________________

EMBARAZO

______________________________________________________

HABITOS

_______________________________________________________

MEDICACION ACTUAL

______________________________________________________

ENF. TRANSMISION SEXUAL

________________________________________________________

VIH

_______________________________________________________

OTROS

CUAL ?________________________________________________

ANTECEDENTES FAMILIARES ___________________________________________________________________________


______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
V.

EXAMEN CLINICO
NORMAL ANORMAL

OBSERVACIONES

LABIOS

______________________________________________________

CARRILLOS

______________________________________________________

LENGUA

______________________________________________________

AMIGDALAS

______________________________________________________

PALADAR DURO

______________________________________________________

PISO DE BOCA

______________________________________________________

FRENILLOS

______________________________________________________

MUCOSA MASTICATORIA

______________________________________________________

PERFIL

RECTO

CONCAVO

CONVEXO

OCLUSION____________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
_
ACTIVIDAD MUSCULAR_________________________________________________________________________________
______________________________________________________________________________________________________
A.T.M. (PALPACION MUSCULAR)

NORMAL

ANORMAL

OBSERVACIONES______________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
VI.

ODONTOGRAMA

____________________________________________

38

____________________________________________

8
1

____________________________________________

37

____________________________________________

7
1

____________________________________________

36

____________________________________________

6
1

____________________________________________

35

____________________________________________

5
1

____________________________________________

34

____________________________________________

4
1

____________________________________________

33

____________________________________________

3
1

____________________________________________

32

____________________________________________

2
1

____________________________________________

31

____________________________________________

1
2

____________________________________________

41

____________________________________________

1
2

____________________________________________

42

____________________________________________

2
2

____________________________________________

43

____________________________________________

3
2

____________________________________________

44

____________________________________________

4
2

____________________________________________

45

____________________________________________

5
2

____________________________________________

46

____________________________________________

6
2

____________________________________________

47

____________________________________________

7
2

____________________________________________

48

____________________________________________

8
OBSERVACIONES______________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
VII.

DIAGNOSTICO PRESUNTIVO
____________________________________________________________________

______________________________________________________________________________________________________
DIAGNOSTICO DEFINITIVO ______________________________________________________________________
______________________________________________________________________________________________________
VIII.

INTERPRETACION DE EXAMENES
PARACLINICOS__________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________
IX.

PRONOSTICO______________________________________________________________________________
____

______________________________________________________________________________________________________
______________________________________________________________________________________________________
X. PLAN DE TRATAMIENTO _________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________

____________________________________
NOMBRE Y FIRMA DEL PACIENTE

_________________________________________
NOMBRE Y FIRMA DEL ODONTOLOGO

COMANDO GENERAL DE LAS FUERZAS MILITARES

DIRECCION GENERAL DE SANIDAD MILITAR


HISTORIA ODONTOLOGICA

HISTORIA CLINICA:
NOMBRES Y APELLIDOS: ________________________________________________ FECHA: ______________________
CUANTAS VECES SE CEPILLA AL DIA? ____________________

EN QUE MOMENTO?___________________

USA SEDA DENTAL? SI ________

EN QUE MOMENTO? __________________

NO ___________

HISTORIA DE CARIES. NUMERO DE DIENTES:


CARIADOS: ________ OBTURADOS:
TOTAL COP: ___________________

____________ EXTRAIDOS:

_____________ PERDIDOS: ______________

RESPONSABLE

FECHA

PORCENTAJE

VESTIBULAR
1

10

11

12

13

14

15

16
PALATINO
LINGUAL

32

31

30

29

28

27

26

25

24

23

22

21

20

19

18

17
VESTIBULAR

NUMERO DE SUPERFICIES CON PLACA BACTERINA TEIDAS ________________________


NUMERO DE SUPERFICIES PRESENTES _______________________

RESPONSABLE

__________%

FECHA

PORCENTAJE

VESTIBULAR
1

10

11

12

13

14

15

16
PALATINO
LINGUAL

32

31

30

29

28

27

26

25

24

23

22

21

20

19

18

17
VESTIBULAR

NUMERO DE SUPERFICIES CON PLACA BACTERINA TEIDAS ________________________


NUMERO DE SUPERFICIES PRESENTES _______________________

RESPONSABLE

__________%

FECHA

PORCENTAJE

VESTIBULAR
1

10

11

12

13

14

15

16
PALATINO
LINGUAL

32

31

30

29

28

27

26

25

24

23

22

21

20

19

18

17
VESTIBULAR

NUMERO DE SUPERFICIES CON PLACA BACTERINA TEIDAS ________________________


NUMERO DE SUPERFICIES PRESENTES _______________________

__________%