HISTORIA CLINICA PEDIATRICA

AFILIACIN
Nombre completo______________________________________________________________
Edad _______________________fecha de nacimiento_______________________________
Sexo_________________________ Direccin ________________________________________
Datos obtenidos de__________________________Confiabilidad_________________________

MOTIVO DE CONSULTA
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

HISTORIA DE LA ENFERMEDAD ACTUAL

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

ANTECEDENTES PERSONALES PATOLGICOS

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

ANTECEDENTES PERSONALES NO PATOLGICOS

Hbitos personales _____________________________________________________________
Lactancia Materna Artificial Mixta
Ablactacin ___________________________________________________________________
Alimentacin__________________________________________________________________
Alergias ______________________________________________________________________
Grupo y factor Sanguneo________________________________________________________
Otros ________________________________________________________________________
_____________________________________________________________________________
Desarrollo Psicomotor
Sonri Sostuvo cabeza Se sent
Se par Camino solo
Control de esfnter vesical anal
Escolaridad actual______________________________________________________________
Otros_________________________________________________________________________
_____________________________________________________________________________
Inmunizacin
BCG__________________________________ Polio_______________________________
Pentavalente___________________________ Rotavirus____________________________
Antineumococica________________________ Influenza estacional___________________
SRP Antiamarillica
Otras ______________________________________________________________________
ANTECEDENTES PERINATALES
Producto de embarazo N_____________ de ________________ semanas de gestacin
Sitio de nacimiento _________________________________________________________
Tipo de Parto Vaginal / Cesrea por que________________________________________
Datos al nacimiento: Peso ____________ Talla_____________ PC___________________
APGAR_____________________________
Problemas al nacimiento_________________________________________________________
_____________________________________________________________________________

ANTECEDENTES FAMILIARES
Nombre completo madre_______________________________________________________
Edad Hbitos
Grupo sanguneo
G P C A
Gineco-obstetricos_____________________________________________________________
_____________________________________________________________________________
Ant. Patolgicos________________________________________________________________
_____________________________________________________________________________

Nombre completo Padre_________________________________________________________

Edad Hbitos
Grupo sanguineo
Ant.Patolgicos________________________________________________________________
_____________________________________________________________________________

Otros_familiares________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

ANAMNESIS POR SISTEMAS

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

EXAMEN FISICO
EXAMEN FISICO GENERAL
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

FC FR T PA
PESO TALLA IMC

EXAMEN FISICO SEGMENTARIO

Cabeza_______________________________________________________________________
_____________________________________________________________________________

ojos__________________________________________________________________________

orejas________________________________________________________________________

nariz_________________________________________________________________________

Boca_________________________________________________________________________
_____________________________________________________________________________

Cuello________________________________________________________________________
_____________________________________________________________________________

Torax_________________________________________________________________________
_____________________________________________________________________________

Corazn_______________________________________________________________________
____________________________________________________________________________

Pulmones_____________________________________________________________________
_____________________________________________________________________________

Abdomen_____________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Extremidades _________________________________________________________________
_____________________________________________________________________________

Genitourinario_________________________________________________________________
_____________________________________________________________________________

Neurolgico___________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

DIAGNOSTICO PRESUNTIVO
1. _______________________________________________________________________
2. _______________________________________________________________________
3. _______________________________________________________________________
4. _______________________________________________________________________
5. _______________________________________________________________________

Elaborado por: ______________________

HISTORIA CLINICA PEDIATRICA

AFILIACIN
Nombre completo______________________________________________________________
Edad _______________________fecha de nacimiento_______________________________
Sexo_________________________ Direccin ________________________________________
Datos obtenidos de__________________________Confiabilidad_________________________

MOTIVO DE CONSULTA
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

HISTORIA DE LA ENFERMEDAD ACTUAL

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

ANTECEDENTES PERSONALES PATOLGICOS

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

ANTECEDENTES PERSONALES NO PATOLGICOS

Hbitos personales _____________________________________________________________
Lactancia Materna Artificial Mixta
Ablactacin ___________________________________________________________________
Alimentacin__________________________________________________________________
Alergias ______________________________________________________________________
Grupo y factor Sanguneo________________________________________________________
Otros ________________________________________________________________________
_____________________________________________________________________________
Desarrollo Psicomotor
Sonri Sostuvo cabeza Se sent
Se par Camino solo
Control de esfnter vesical anal
Escolaridad actual______________________________________________________________
Otros_________________________________________________________________________
_____________________________________________________________________________
Inmunizacin
BCG__________________________________ Polio_______________________________
Pentavalente___________________________ Rotavirus____________________________
Antineumococica________________________ Influenza estacional___________________
SRP Antiamarillica
Otras ______________________________________________________________________

ANTECEDENTES PERINATALES
Producto de embarazo N_____________ de ________________ semanas de gestacin
Sitio de nacimiento _________________________________________________________
Tipo de Parto Vaginal / Cesrea por que________________________________________
Datos al nacimiento: Peso ____________ Talla_____________ PC___________________
APGAR_____________________________
Problemas al nacimiento_________________________________________________________
_____________________________________________________________________________

ANTECEDENTES FAMILIARES
Nombre completo madre_______________________________________________________
Edad Hbitos
Grupo sanguneo
G P C A
Gineco-obstetricos_____________________________________________________________
_____________________________________________________________________________
Ant. Patolgicos________________________________________________________________
_____________________________________________________________________________

Nombre completo Padre_________________________________________________________

Edad Hbitos
Grupo sanguineo
Ant.Patolgicos________________________________________________________________
_____________________________________________________________________________

Otros_familiares________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

ANAMNESIS POR SISTEMAS

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

EXAMEN FISICO
EXAMEN FISICO GENERAL
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

FC FR T PA
PESO TALLA IMC

EXAMEN FISICO SEGMENTARIO

Cabeza_______________________________________________________________________
_____________________________________________________________________________
ojos__________________________________________________________________________

orejas________________________________________________________________________

nariz_________________________________________________________________________

Boca_________________________________________________________________________
_____________________________________________________________________________

Cuello________________________________________________________________________
_____________________________________________________________________________

Torax_________________________________________________________________________
_____________________________________________________________________________

Corazn_______________________________________________________________________
____________________________________________________________________________

Pulmones_____________________________________________________________________
_____________________________________________________________________________

Abdomen_____________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Extremidades _________________________________________________________________
_____________________________________________________________________________

Genitourinario_________________________________________________________________
_____________________________________________________________________________

Neurolgico___________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

DIAGNOSTICO PRESUNTIVO
1. _______________________________________________________________________
2. _______________________________________________________________________
3. _______________________________________________________________________
4. _______________________________________________________________________
5. _______________________________________________________________________

Elaborado por: ______________________

HISTORIA CLINICA PEDIATRICA

AFILIACIN
Nombre completo______________________________________________________________
Edad _______________________fecha de nacimiento_______________________________
Sexo_________________________ Direccin ________________________________________
Datos obtenidos de__________________________Confiabilidad_________________________

MOTIVO DE CONSULTA
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

HISTORIA DE LA ENFERMEDAD ACTUAL

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

ANTECEDENTES PERSONALES PATOLGICOS

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

ANTECEDENTES PERSONALES NO PATOLGICOS

Hbitos personales _____________________________________________________________
Lactancia Materna Artificial Mixta
Ablactacin ___________________________________________________________________
Alimentacin__________________________________________________________________
Alergias ______________________________________________________________________
Grupo y factor Sanguneo________________________________________________________
Otros ________________________________________________________________________
_____________________________________________________________________________
Desarrollo Psicomotor
Sonri Sostuvo cabeza Se sent
Se par Camino solo
Control de esfnter vesical anal
Escolaridad actual______________________________________________________________
Otros_________________________________________________________________________
_____________________________________________________________________________
Inmunizacin
BCG__________________________________ Polio_______________________________
Pentavalente___________________________ Rotavirus____________________________
Antineumococica________________________ Influenza estacional___________________
SRP Antiamarillica
Otras ______________________________________________________________________

ANTECEDENTES PERINATALES
Producto de embarazo N_____________ de ________________ semanas de gestacin
Sitio de nacimiento _________________________________________________________
Tipo de Parto Vaginal / Cesrea por que________________________________________
Datos al nacimiento: Peso ____________ Talla_____________ PC___________________
APGAR_____________________________
Problemas al nacimiento_________________________________________________________
_____________________________________________________________________________

ANTECEDENTES FAMILIARES
Nombre completo madre_______________________________________________________
Edad Hbitos
Grupo sanguneo
G P C A
Gineco-obstetricos_____________________________________________________________
_____________________________________________________________________________
Ant. Patolgicos________________________________________________________________
_____________________________________________________________________________

Nombre completo Padre_________________________________________________________

Edad Hbitos
Grupo sanguineo
Ant.Patolgicos________________________________________________________________
_____________________________________________________________________________

Otros_familiares________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

ANAMNESIS POR SISTEMAS

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

EXAMEN FISICO
EXAMEN FISICO GENERAL
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

FC FR T PA
PESO TALLA IMC

EXAMEN FISICO SEGMENTARIO

Cabeza_______________________________________________________________________
_____________________________________________________________________________

ojos__________________________________________________________________________
orejas________________________________________________________________________

nariz_________________________________________________________________________

Boca_________________________________________________________________________
_____________________________________________________________________________

Cuello________________________________________________________________________
_____________________________________________________________________________

Torax_________________________________________________________________________
_____________________________________________________________________________

Corazn_______________________________________________________________________
____________________________________________________________________________

Pulmones_____________________________________________________________________
_____________________________________________________________________________

Abdomen_____________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Extremidades _________________________________________________________________
_____________________________________________________________________________

Genitourinario_________________________________________________________________
_____________________________________________________________________________

Neurolgico___________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

DIAGNOSTICO PRESUNTIVO
1. _______________________________________________________________________
2. _______________________________________________________________________
3. _______________________________________________________________________
4. _______________________________________________________________________
5. _______________________________________________________________________

Elaborado por: ______________________

HISTORIA CLINICA PEDIATRICA

AFILIACIN
Nombre completo______________________________________________________________
Edad _______________________fecha de nacimiento_______________________________
Sexo_________________________ Direccin ________________________________________
Datos obtenidos de__________________________Confiabilidad_________________________

MOTIVO DE CONSULTA
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

HISTORIA DE LA ENFERMEDAD ACTUAL

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

ANTECEDENTES PERSONALES PATOLGICOS

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

ANTECEDENTES PERSONALES NO PATOLGICOS

Hbitos personales _____________________________________________________________
Lactancia Materna Artificial Mixta
Ablactacin ___________________________________________________________________
Alimentacin__________________________________________________________________
Alergias ______________________________________________________________________
Grupo y factor Sanguneo________________________________________________________
Otros ________________________________________________________________________
_____________________________________________________________________________
Desarrollo Psicomotor
Sonri Sostuvo cabeza Se sent
Se par Camino solo
Control de esfnter vesical anal
Escolaridad actual______________________________________________________________
Otros_________________________________________________________________________
_____________________________________________________________________________
Inmunizacin
BCG__________________________________ Polio_______________________________
Pentavalente___________________________ Rotavirus____________________________
Antineumococica________________________ Influenza estacional___________________
SRP Antiamarillica
Otras ______________________________________________________________________

ANTECEDENTES PERINATALES
Producto de embarazo N_____________ de ________________ semanas de gestacin
Sitio de nacimiento _________________________________________________________
Tipo de Parto Vaginal / Cesrea por que________________________________________
Datos al nacimiento: Peso ____________ Talla_____________ PC___________________
APGAR_____________________________
Problemas al nacimiento_________________________________________________________
_____________________________________________________________________________

ANTECEDENTES FAMILIARES
Nombre completo madre_______________________________________________________
Edad Hbitos
Grupo sanguneo
G P C A
Gineco-obstetricos_____________________________________________________________
_____________________________________________________________________________
Ant. Patolgicos________________________________________________________________
_____________________________________________________________________________

Nombre completo Padre_________________________________________________________

Edad Hbitos
Grupo sanguineo
Ant.Patolgicos________________________________________________________________
_____________________________________________________________________________

Otros_familiares________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

ANAMNESIS POR SISTEMAS

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

EXAMEN FISICO
EXAMEN FISICO GENERAL
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

FC FR T PA
PESO TALLA IMC

EXAMEN FISICO SEGMENTARIO

Cabeza_______________________________________________________________________
_____________________________________________________________________________

ojos__________________________________________________________________________

orejas________________________________________________________________________
nariz_________________________________________________________________________

Boca_________________________________________________________________________
_____________________________________________________________________________

Cuello________________________________________________________________________
_____________________________________________________________________________

Torax_________________________________________________________________________
_____________________________________________________________________________

Corazn_______________________________________________________________________
____________________________________________________________________________

Pulmones_____________________________________________________________________
_____________________________________________________________________________

Abdomen_____________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Extremidades _________________________________________________________________
_____________________________________________________________________________

Genitourinario_________________________________________________________________
_____________________________________________________________________________

Neurolgico___________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

DIAGNOSTICO PRESUNTIVO
1. _______________________________________________________________________
2. _______________________________________________________________________
3. _______________________________________________________________________
4. _______________________________________________________________________
5. _______________________________________________________________________

Elaborado por: ______________________

HISTORIA CLINICA PEDIATRICA

AFILIACIN
Nombre completo______________________________________________________________
Edad _______________________fecha de nacimiento_______________________________
Sexo_________________________ Direccin ________________________________________
Datos obtenidos de__________________________Confiabilidad_________________________
MOTIVO DE CONSULTA
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

HISTORIA DE LA ENFERMEDAD ACTUAL

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

ANTECEDENTES PERSONALES PATOLGICOS

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

ANTECEDENTES PERSONALES NO PATOLGICOS

Hbitos personales _____________________________________________________________
Lactancia Materna Artificial Mixta
Ablactacin ___________________________________________________________________
Alimentacin__________________________________________________________________
Alergias ______________________________________________________________________
Grupo y factor Sanguneo________________________________________________________
Otros ________________________________________________________________________
_____________________________________________________________________________
Desarrollo Psicomotor
Sonri Sostuvo cabeza Se sent
Se par Camino solo
Control de esfnter vesical anal
Escolaridad actual______________________________________________________________
Otros_________________________________________________________________________
_____________________________________________________________________________
Inmunizacin
BCG__________________________________ Polio_______________________________
Pentavalente___________________________ Rotavirus____________________________
Antineumococica________________________ Influenza estacional___________________
SRP Antiamarillica
Otras ______________________________________________________________________

ANTECEDENTES PERINATALES
Producto de embarazo N_____________ de ________________ semanas de gestacin
Sitio de nacimiento _________________________________________________________
Tipo de Parto Vaginal / Cesrea por que________________________________________
Datos al nacimiento: Peso ____________ Talla_____________ PC___________________
APGAR_____________________________
Problemas al nacimiento_________________________________________________________
_____________________________________________________________________________
ANTECEDENTES FAMILIARES
Nombre completo madre_______________________________________________________
Edad Hbitos
Grupo sanguneo
G P C A
Gineco-obstetricos_____________________________________________________________
_____________________________________________________________________________
Ant. Patolgicos________________________________________________________________
_____________________________________________________________________________

Nombre completo Padre_________________________________________________________

Edad Hbitos
Grupo sanguineo
Ant.Patolgicos________________________________________________________________
_____________________________________________________________________________

Otros_familiares________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

ANAMNESIS POR SISTEMAS

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

EXAMEN FISICO
EXAMEN FISICO GENERAL
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

FC FR T PA
PESO TALLA IMC

EXAMEN FISICO SEGMENTARIO

Cabeza_______________________________________________________________________
_____________________________________________________________________________

ojos__________________________________________________________________________

orejas________________________________________________________________________

nariz_________________________________________________________________________
Boca_________________________________________________________________________
_____________________________________________________________________________

Cuello________________________________________________________________________
_____________________________________________________________________________

Torax_________________________________________________________________________
_____________________________________________________________________________

Corazn_______________________________________________________________________
____________________________________________________________________________

Pulmones_____________________________________________________________________
_____________________________________________________________________________

Abdomen_____________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Extremidades _________________________________________________________________
_____________________________________________________________________________

Genitourinario_________________________________________________________________
_____________________________________________________________________________

Neurolgico___________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

DIAGNOSTICO PRESUNTIVO
1. _______________________________________________________________________
2. _______________________________________________________________________
3. _______________________________________________________________________
4. _______________________________________________________________________
5. _______________________________________________________________________

Elaborado por: ______________________