HISTORIA CLÍNICA

HISTORIA ALOPÁTICA GENERAL

H.C.N°
Fecha
DATOS PERSONALES Y ANTECEDENTES:

Nombre. ___________________________________________
Edad: Peso: Talla:
Sexo:
Dirección: __________________________________________
Profesión: _______________________________________________________________
Trabajo, actividad: __
Estado Civil______________________________________ Hijos____________________

HISTORIA CLINICA

Enfermedad que padece según diagnostico occidental:

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Tratamiento:_________________________________________________________
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Comente si ha sido operado (SI) ___________________________ (NO) _______

Consume medicamentos (SI) (NO)
Cuales?, por cuanto tiempo?
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¿Se ha realizado exámenes clinicos en el último periodo? (SI) (NO)
Indique
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¿Ha tenido o sufre de depresión? (SI) (NO)

Si es si, comente si ha recibido atención medica

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Comente un breve resumen sobre su estado de salud a actual:

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Marque con un X donde tiene dolor físico

D / I

¿Desde cuándo?

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HISTORIA ACUPUNTURAL

INSPECCIÓN Y OBSERVACIÓN
Estado Neuro-Psiquico y Coordinacion Motora

Trastornos de la motrocidad:
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Trastornos del lenguaje:

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Trastornos sensitivos:
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Trastornos en los reflejos tendinosos:

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ESTADO EMOCIONAL:

Depresivo:
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Estresado:
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Ansioso:
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Triste:

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Desorientado:

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Eufórico:

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Obsesivo
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