HISTORIA CLINICA

FACULTAD DE MEDICINA
Semiología medica

DATOS DE FILIACION
1. Nombre completo:
2. Edad aparente :
3. Edad cronológica :
4. Sexo :
5. Raza :
6. Estado civil :
7. Ocupación :
8. Nacido en :
9. Procedencia :
10. Residente en : Dirección:
Teléfono
11. Documento de identificación :
12. Fecha de admisión :
13. Fecha de toma de historia :
14. Fuente de la historia :
15. Confiabilidad del historia :
16. Nombre del médico :
17. Nombre del docente: Dr.

II. MOTIVO DE CONSULTA

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III. ENFERMEDAD ACTUAL

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IV. ANTECEDENTES PERSONALES
• Médicos
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• Quirúrgicos y traumáticos
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• Alérgicos
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• Intoxicaciones
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• Transfunsionales
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• Inmunizaciones
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• Hereditarios
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• Historia Ginecoobstetrica
Menarquia:
Ciclos menstruales:
Dismenorrea:
Fecha de ultima menstruación F.U.M. :
Uso de Anticonceptivos: Que tipo?
Embarazos, Partos, Abortos, Cesáreas (G____P____A____C____)
Mortinatos, Partos preterminos, enfermedades del embarazo
Fecha ultimo parto :
Menopausia? : drogas de terapia de reemplazo hormonal? :
Citología (fecha):
HISTORIA SOCIAL Y HÁBITOS

Tabaco: Fuma: Si____ No____

Desde cuando_______________ Con qué frecuencia_______________Cuántos al día____________
Si dejo de fumar hace cuanto______________________
Consume alcohol: Si____ No_____
Desde cuándo: _____________ Con qué frecuencia: ___________ Tipo de alcohol: _____________
Si dejo de tomar hace cuánto: ____________________
Adicción a drogas: Si_____ No_____
Tipo de droga: Frecuencia:
Hábitos alimenticios: Grasas______ Café _____ Consumo de sal _______
Comidas rápidas:
Actividad física y/o deportiva: Si_____ No_____
Tipo de actividad: Veces por semana:

V. ANTECEDENTES FAMILIARES
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VI. REVISION POR SISTEMAS

• SÍNTOMAS GENERALES
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• CABEZA ÓRGANOS DE LOS SENTIDOS

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Ojos:____________________________________________________________________________
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Oidos____________________________________________________________________________
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Nariz:____________________________________________________________________________
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Boca y garganta:___________________________________________________________________
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 Cuello:
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 • Mamas:
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• Aparato Respiratorio:
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• Cardio circulatorio
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• Aparato gastrointestinal:
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• Aparato urinario
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• Aparato genital
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• Aparato osteomuscular
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• Sistema nervioso
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VII. EXAMEN FISICO

• DESCRIPCIÓN GENERAL DEL PACIENTE PIEL Y MUCOSAS

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• SIGNOS VITALES
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• CABEZA, CRANEO Y CUERO CABELLUDO

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BOCA Y GARGANTA:
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CUELLO
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• TORAX
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• CORAZÓN
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 • PULMONES
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• ABDOMEN
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• GENITOURINARIO
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• APARATO LOCOMOTOR
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• VASCULAR PERIFERICO
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ESFERA MENTAL
1º) conciencia
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2º) orientación
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3º) memoria
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4º) estado de ánimo, juicio y raciocinio, instrospeccion, prospeccion. Inteligencia
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VIII. IMPRESIÓN DIAGNOSTICA
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IX. PARACLINICOS
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X. DIAGNOSTICO
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XI. TRATAMIENTO
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XII. EVOLUCION
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Firma