Historia Clnica

Ficha de Identificacin.
Nombre: _______________________________________________________
Sexo__________ Edad_____________ Ocupacin____________________
Padecimiento actual
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Estado civil____________________
Hijos_____________

Antecedentes Personales Patolgicos.(Detallar los antecedentes de importancia

clnica, as como el tratamiento que recibe para cada situacin comrbida y su duracin)

Cardiovasculares
Digestivos
Diabetes
Pulmonares
Quirrgicos
Alrgicos
Renales
Transfusiones
Medicamentos
Especifique___________________________________________________
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Antecedentes Personales No Patolgicos

(se anotar aqu lo relacionado a

tabaquismo, uso de alcohol, as como diferentes adicciones y su duracin, de igual forma se anotarn aqu,
de requerirse, los antecedentes sexuales del paciente.)

Alcohol
Tabaquismo

Drogas
Inmunizaciones

Otros: ____________
______________

Antecedentes Familiares:
Padre: Vivo Si
No
Enfermedades que padece: __________________________________________
Madre: Viva S
No
Enfermedades que padece: __________________________________________
Hermanos: Cuntos? ______ Vivos _____
Enfermedades que padecen: _________________________________________

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Exploracin fsica.
Signos Vitales. T.A. (brazo derecho) ___________
F.C.______________
T.A. (brazo izquierdo) ____________
Frec. Resp.________
Temp.______ Peso_____ Talla_____
Cabeza y Cuello__________________________________________
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Trax__________________________________________________
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Abdomen.
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Extremidades.
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Zona de dolor
Palpacin
Especifique: Actividad

Movilizacin
Reposo

Valoracin ortopdica

Referido
Despus de la actividad

POSTURA: _________________________________________________________

Puntos de Referencia:

Estado Emocional y mental:

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Diagnostico:
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Hiptesis
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Tratamiento:
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REFERENCIAS:

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