HISTORIA CLNICA

Paciente de la cama no._____

Ficha Clnica
Nombre:_____________________________________________________________
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Sexo: ________________
Estado civil:
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Ocupacin:___________________________________________________________
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Lugar de Nacimiento:________________ Lugar de Origen:
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Motivo de la consulta
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Principio y Evolucin del padecimiento actual (PEPA)
Orden cronolgico
Tiempo previo a su ingreso
Signos y sntomas que se
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Redaccin
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Exploracin fsica

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Antecedentes Heredo Familiares
Abuelos
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Padres
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Tos
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Primos
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Hermanos
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Sobrinos
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Esposo(a)/p
areja
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Hijos
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Nietos
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Antecedentes personales no patolgicos

Medio:
Urbano
Rural
Vivienda:
Propia
Rentada
Prestada
Tipo de piso
Tierra
Cemento
Vitropiso
Servicios:
Agua
Luz
Drenaje
Letrina
Fecalismo aire libre
Cocina con gas
Cocina lea
Otros:__________________________
Animales:____________________________________________________________
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Fauna
nociva:_______________________________________________________________
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Actividad fsica (Tipo, duracin, frecuencia)
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Alimentacin (Menu que consume regularmente)
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Escolaridad:___________________
Higiene:_________________________________________
Inmunizaciones:______________________________________________________
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Toxicomanias:_______________________________________________________
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Preferencia sexual (numero de
parejas)_____________________________________________
Antecedentes gineco-obstetricos
Gesta:________
Partos:________
Abortos:________
Cesareas
(mot):______________
Menarca________
FUM:____________
Ritmo:____________
FUP:____________
IVSA:____________
DOC:____________
Uso de anticonceptivos (Tipo y desde cuando se utiliza)
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Antecedentes personales patolgicos
Quirrgicos___________________________________________________________
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Transfusionales (Motivo, numero de

unidades):_______________________________________
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Traumaticos:
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Hospitalizaciones:
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Infeccioso (tuberculosis, sfilis, hepatitis, faringoamigdalitis, etc):
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Endocrinos:
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Neoplsicos:__________________________________________________________
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Cardiovasculares:_____________________________________________________
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_________________Respiratorios:
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Neurolgicos:
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Hematologicos:_______________________________________________________
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Psiquiatricos:_________________________________________________________
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Alrgicos:_____________________________________________________________
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Renales:______________________________________________________________
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Enfermedades de infancia:
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Gastrointestinales:
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Reumatolgicas:
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Dermatolgicas:______________________________________________________
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Interrogatorio por aparatos y sistemas
Sntomas generales (fiebre, prdida de peso, astenia, anorexia)
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Dermatologicos
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Ojos
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Nariz y garganta
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Dental
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Mama
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Respiratorio
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Cardiovascular
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Gasrtointestinal
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Urinario
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Genital masculino
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Genital femenino
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Sexualidad
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Msculo esqueletico
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Reumatologia
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Hematologia
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Endocrinologa
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SN
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Exploracion General
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