MODELO DE HISTORIA CLNICA

Fecha:

Mdico: ________________________________.

DATOS PERSONALES
Apellido y Nombre:
_________________________________________________________________________.
Sexo: _______. Fecha de Nacimiento: _________. Estado Civil: ___________. Ocupacin:
_______________.
Domicilio: _____________________________________________________________. TE:
______________.
Residencia:
_______________________________________________________________________________ .

MOTIVO DE CONSULTA

ANTECEDENTES DE LA ENFERMEDAD ACTUAL

ANAMNESIS SISTEMICA
_____________________________________________________________
1- Sntomas Generales: fiebre,
_____________________________________________________________
perdida de peso, astenia, fatiga,
_____________________________________________________________
otros.
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
2 - Piel y faneras: prurito, lesiones _____________________________________________________________
primarias y secundarias,
_____________________________________________________________
alteraciones de uas y cabellos,
_____________________________________________________________
otros.
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
3 - TCS: edema, tumoraciones,
_____________________________________________________________
otros.
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
4 - SOMA: dolor, tumefaccin,
_____________________________________________________________
fuerza muscular, limitacin del
_____________________________________________________________
movimiento, otros.
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
5 - Ap. Cardiovascular: disnea,
_____________________________________________________________
palpitaciones, dolor precordial,
_____________________________________________________________
sncope, claudicacin intermitente, _____________________________________________________________
otros.
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
6 - Ap.Respiratorio: epistaxis, tos, _____________________________________________________________
expectoracin, hemptisis, dolor
_____________________________________________________________
torcico, cianosis, otros.
_____________________________________________________________
______________________________
_____________________________________________________________
7 - Ap. Digestivo: halitosis,
_____________________________________________________________
disfagia, regurgitacin, acidez,
_____________________________________________________________
pirosis, nauseas y vmitos,
_____________________________________________________________
hematemesis, alteraciones del
_____________________________________________________________
hbito intestinal, otros.
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
8 - Ap. Genitourinario: disuria,
_____________________________________________________________
polaquiuria, nicturia, hematuria,
___________________________________________________
incontinencia, dolor, alteraciones
_____________________________________________________________
ciclo menstrual, alteraciones
_____________________________________________________________
sexuales, otros
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
9 - Sistema Nervioso: cefalea,
_____________________________________________________________
mareos, vrtigo, sensibilidad,
_____________________________________________________________
motricidad, temblor, alteraciones
_____________________________________________________________
de la visin, audicin, otros.
____________________________________________________.

ANTECEDENTES PERSONALES
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
2- Inmunizaciones.
____________________________________________________________
____________________________________________________________
3- Vivienda y medio ambiente.
____________________________________________________________
____________________________________________________________
4- Socioeconmicos.
____________________________________________________________
____________________________________________________________
5- Patolgicos: mdicos, alrgicos, ____________________________________________________________
quirrgicos, traumticos.
____________________________________________________________
____________________________________________________________
6-Txico-Medicamentosos: tabaco, ____________________________________________________________
____________________________________________________________
alcohol, sustancias de uso
____________________________________________________________
indebido, medicamentos, otros.
____________________________________________________________
____________________________________________________________
7-Epidemiolgicos: Chagas,
____________________________________________________________
HIV/Sida, Brucelosis,
____________________________________________________________
Toxoplasmosis, transfusiones,
____________________________________________________________
residencias anteriores, otros.
____________________________________________________________
____________________________________________________________
8-Heredo-Familiares.
____________________________________________________________
____________________________________________________________
9- Estudios preventivos.
____________________________________________________________
____________________________________________________________
10- Otros.
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
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____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
1-Fisiolgicos : menarca, ciclo
menstrual, fecha ltima
menstruacin, embarazos, partos,
alimentacin, actividad fsica,
sueo, diuresis y catarsis, actividad
sexual, otros.

1-Inspeccin General

EXAMEN FISICO
Examen General
Estado de conciencia: __________________________________________.
Actitud: _____________________________________________________.
Decbito: ____________________________________________________.
Marcha: _____________________________________________________.
Facie: _______________________________________________________.

2-Mediciones y Controles

FC: _____________ TA: _____________ FR: __________ T: _______.

Peso: ___________ Altura: ___________ IMC: ___________________.

3-Piel y faneras:

_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
________________________________________________________.

4-TCS:

_____________________________________________________________
_____________________________________________________________
__________________________________________________________.

5-SOMA:

_____________________________________________________________
_____________________________________________________________
__________________________________________________________.

1-Cabeza y cuello:
2-Ap. Respiratorio:

3-Mamas.
4-Ap. Cardiovascular:

5-Abdomen:

6-Ap. Genitourinario:
7-Sistema Nervioso:

Examen Segmentario
_____________________________________________________________
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4

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