Bachiller:________________________

UNIVERSIDAD DE CARABOBO
ASIGNATURA SEMIOLOGIA
HISTORIA CLINICA

Fecha:
Hora:

I PARTE ANAMNESIS O INTERROGATORIO

Servicio:

Ficha Patronmica
Nombre y Apellido:
Sexo:

Edad:

Fecha de Nacimiento:

Lugar de Nacimiento:

Cdula de Identidad:

Grupo tnico:

Nacionalidad:

Telfono:

Direccin Actual:

Religin:

Estado Civil:

Ocupacin:

Avisar en caso de Emergencia a:

Telfono:

Direccin Actual:

Profesin:
Parentesco:

Motivo de Consulta
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Enfermedad Actual
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Diagnstico Sindromtico

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I.
HISTORIA FAMILIAR
1. Estado de salud y/o causa de muerte
2. Antecedentes patolgicos familiares
2.1 Alcoholismo
2.2 Artritis
2.3 Asma
2.4 Cncer
2.5 Cardiovasculares
2.6 Enf. Metablicas
(Endocrinas)
2.7 T.B.C
2.8 Enf Digestivas
Enf. Renales
2.9 Enf. Alrgicas
2.10 Neuromentales
2.11 Sfilis
2.12 Discrasias
Sanguneas
2.13 Otras

Padres:____________________________________________________________________________________
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Hermanos:________________________________________________________________________________
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Hijos:______________________________________________________________________________________
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II. HISTORIA PERSONAL

4. Hbitos Psico-Biolgicos
4.1 Alimentacin
4.2 Apetito
4.3 Catarsis Intestinal
4.4 Diuresis
4.5 Sueo
4.6 Alcoholismo
4.7 Tabaquismo
4.8 Drogas
4.9 Medicamentos
4.10 Sexuales
4.11 Recreacin
4.12 Actividad Fsica
4.13 Aseo
4.14 Tipo de vivienda
4.15 Otros

5. Inmunizaciones
5.1 Viruela
5.2 Toxoide Tetnica
5.3 Antiamarilica
5.4 BCG
5.5 Divalente
5.6 Hepatitis
5.7 Antipolio
5.8 Influenza
5.9 AH1N1
5.10 Otras

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6. Antecedentes Epidemiolgicos
6.1
Lugares
de
Residencia:
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6.2 Caractersticas de la Vivienda: Piso _________________ Paredes _____________________ Techo _____________________
Nro de Hab ___
Disposicin de Excretas ______________________ Disposicin de Basura ____________________________ Aguas: Negras
____ Blancas ____
Nro
de
Baos
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Nro
de
Personas
_____
Tenencia
de
la
vivienda:

7. Antecedentes Ginecolgicos y Obsttricos

7.1 Menarquia
7.2 Sexarquia
7.3 Menopausia
7.4 Partos
7.5 Abortos
7.6 Cesreas
7.7 Hijos Vivos
7.8 Menstruacin
7.9 Fecha de la ltima
menstruacin
7.10
Met.
Anticonceptivos
7.11 Flujo Vaginal
7.12 Fecha de la
ltima citologa

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8. Antecedentes Quirrgicos
y Traumticos
8.1 Operacin
8.2 Traumatismos
8.3 Fracturas
8.4
Prdida
conciencia

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de
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9. Antecedentes Alrgicos
9.1
9.2
9.3
9.4

Inhalatorias
Alimentarias
Cutneas
Medicamentos

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Antecedentes Patolgicos
10. Enfermedades de la Infancia
10.1 Sarampin
10.2 Tos Ferina
10.3 Rubeola
10.4 Lechina
10.5 Parotiditis
10.6 Amigdalitis
10.7 Malaria
10.8 Sfilis
10.9 Parasitosis
10.10 Conjuntivitis
10.11 Otitis
10.12 Enf. De Piel
10.13 Otras

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11. Enfermedades Mdicas

11.1
11.2
11.3
11.4
11.5
11.6
11.7
11.8
11.9

Difteria
Gripe
Influenza
Chancros
Sfilis
Micosis
Conjuntivitis
Sinusitis
Otitis

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11.10 Asma
11.11 Amigdalitis
11.12 Cardiopatas
11.13 Gastropatas
11.14
Fiebres
prolongadas
11.14 Convulsiones
11.15 Hepatitis
11.16 Mononucleosis
11.17 Otros

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Hospitalizaciones:
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III. INTERROGATORIO POR APARATOS Y SISTEMAS

12. Piel, Pelo y Uas
12.1 Erupcin
12.2 Prurito
12.3
Cambio
de
Pigmentacin
12.4
Aparicin
de
tumoraciones
y
lunares
12.5
Cambios
de
apariencia en lunares
12.6
Cambios
en
textura de piel y uas
12.7 Cada o fragilidad
en cabello
12.8 Cianosis
12.9 Edemas
12.10 Otros

13. Cabeza
13.1
13.2
13.3
13.4
13.5

Cefalea
Mareos
Vrtigo
Sncope
Otros

14. Ojos
14.1
14.2
14.3
14.4
14.5

Agudeza Visual
Diplopa
Secreciones
Lentes
Otros

15. Odo
15.1
15.2
15.3
15.4

Agudeza Auditiva
Dolor
Secreciones
Otros

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16. Nariz
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16.1 Anosmia
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16.2 Hiposmia
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16.3 Sinusitis
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16.4 Epistaxis
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16.5 Rinorrea
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16.6 Obstruccin nasal
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16.7 Otros
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17. Boca y Garganta
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17.1 Mucosa
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17.2
Condicin
de
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dientes
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17.3 Halitosis
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17.4 Glosodinia
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17.5 Odinofagia
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17.6 Disfagia
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17.7 Ronquera
17.8 Dolor
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17.9 Otros
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18. Cuello
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18.1
Dolor
a
la
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movilizacin
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18.2 Inflamacin
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18.3 Adenomegalias
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18.4 Otro
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19. Respiratorio
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19.1 Disnea
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19.2 Tos
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19.3 Dolor
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19.4 Esputos
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19.5 Hemoptisis
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19.6 Otros
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20. Cardiovascular __________________________________________________________________________________________
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20.1 Palpitaciones
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20.2 Dolor Torcico
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20.3 Desmayo
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20.4 Disnea
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20.5
Aumento
de
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volumen o frialdad en
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los
miembros
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inferiores
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20.6 Otras
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21. Gastrointestinal_________________
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21.1 Apetito
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21.2 Dolor Abdominal
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21.3
Nauseas
y
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Vmitos
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21.4 Rectorragia
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21.5 Pirosis
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21.6 Flatulencias
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21.7 Eructos
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21.8 Melena
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21.9 Hemorroides
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21.10 Ulceras
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21.11 Hemorroides
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21.12 Dolor Rectal
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21.13 Esteatorrea
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21.14 Acolia
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21.15 Tenesmo
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21.16 Otros
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22. Genitourinario __________________________________________________________________________________________
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22.1 Disuria
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22.2 Nocturia
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22.3 Hematuria
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22.4 Incontinencia
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22.5 Miccin
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22.6 Secreciones
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22.7 Prostatismo
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22.8 Otros
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23. Neurolgico
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23.1 Nerviosismo
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23.2
Perdida
de
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memoria
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23.3 Desorientacin
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23.4 Marcha
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23.5 Personalidad
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23.6 Parlisis
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23.7 Convulsiones
23.8 Sueo-Vigilia
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23.9
24. Otros
seo-muscular __________________________________________________________________________________________
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24.1 Debilidad
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24.2 Dolor
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24.3 Fracturas
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24.4
Dolor
en
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articulaciones
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24.5 Deformaciones en
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articulaciones
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24.6 Otros
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Presin Arterial: ________________
Frecuencia Respiratoria: Temperatura:
Sistlica:
Diastlica:
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Pulso:
Caractersticas de Pulso y Arterias:
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Talla:

Peso:

IMC:

Circunferencia abdominal:

Circunferencia braquial:
II PARTE EXAMEN FSICO