FACULTAD DE MEDICINA UNIVERSIDAD COOPERATIVA DE SEMIOLOGIA

COLOMBIA
IPS:_____________________ CIUDAD: ______________
FECHA Y HORA: ______________________
HISTORIA CLINICA _____________________ No. ___________________
AMBITO DE REALIZACION: ________________
IDENTIFICACION
NOMBRES:________________________________APELLIDOS:_______________________________
TIPO DE IDENTIFICACION: _______________ No. IDENTIFICACION: ___________________________
EDAD: _____________ SEXO:_____________ ESTADO CIVIL;_____________________ OCUPACION:__________
GRUPO ETNICO: ___________________ RELIGION: ______________ ESCOLARIDAD: ________
NATURAL:_____________________ RESIDENCIA:_______________________ PROCEDENCIA:________
DIRECCION: ________________________________ TELEFONO:________________________
REGIMEN EN EL SGSS:________________________
ENTIDAD :____________________ TIPO AFILIADO: __________
ACOMPAÑANTE:________________________ RESPONSABLE:_______________________________
DIRECCION TELEFONO RESPONSABLE:_______________________ PARENTESCO RESPONSABLE: _________________
CAUSA EXTERNA:_______________________ FINALIDAD:____________________________________

MOTIVO DE CONSULTA:____________________________________
ENFERMEDAD ACTUAL;
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ANTECEDENTES PERSONALES
ANTECEDENTES PATOLOGICOS:___________________________________________________
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ANTECEDENTES FARMACOLOGICOS: _________________________________________________________________
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ANTECEDENTES QUIRURGICOS: ____________________________________________________
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ANTECEDENTES INMUNOLOGICOS :__________________________________________________
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ANTECEDENTES ALERGICOS ;_____________________________________________________________________
ANTECEDENTES TRANSFUSIONALES Y GRUPO SANGUINEO:________________________________________
ANTECEDENTES SICO SOCIALES:________________________________________________________________
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ANTECEDENTES OCUPACIONALES:________________________________________________________________
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HABITOS DE VIDA SALUDABLES:_________________________________________________________________
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Sede Santa Marta

FACULTAD DE MEDICINA UNIVERSIDAD COOPERATIVA DE SEMIOLOGIA
COLOMBIA
ANTECEDENTES OBSTETRICOS;
M: _________ FUM;______________CICLOS:____________
DURACION:_________INICIO VIDA SEXUAL:_____
G: ____ p:_____ A:______ C:______ MORTINATOS:___________ HIJOS VIVOS:__________
PLANIFICACION:_____________________ F ULTIMA CITOLOGIA:_____________ RESULTADO:_____________

ANTECEDENTES FAMILIARES
PADRE:____________________________________ MADRE:_______________________________
HERMANOS_______________ HIJOS:_________________
OTROS:__________________________________________________________________________________

REVISION POR SISTEMAS

SINTOMAS GENERALES __________________________________________________________________________

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PIEL Y ANEXOS __________________________________________________________________________
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CABEZA, CARA, CUELLO __________________________________________________________________________
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ORGANO DE LOS SENTIDOS :________________________
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BOCA Y FARINGE _________________________________________________________________________
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CARDIO PULMONAR _________________________________________________________________________
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ABDOMEN ________________________________________________________________________
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GENITOURINARIO _________________________________________________________________________
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LOCOMOTOR EXTREMIDADES:_____________________________
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NEUROPSIQUIATRICO _________________________________________________________________________
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EXAMEN FISICO
SIGNOS VITALES TA: ______________ PULSO:__________ TEMP:______________F.RESP.________________
SATURACION O2:_______
PESO:__________ TALLA:_________ IMC:_______________

ESTADO GENERAL:___________________________________________________________________________
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PIEL Y ANEXOS ;___________________________________________________________________________
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CABEZA, CRANEO, CARA, CUELLO :____________________________________________________________
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OJOS: ______________________________________________________________________________________

Sede Santa Marta

FACULTAD DE MEDICINA UNIVERSIDAD COOPERATIVA DE SEMIOLOGIA
COLOMBIA
NARIZ OLFATO_________________________________________________________________________________
OIDOS _______________________________________________________________________________________
BOCA:_______________________________________________________________________________________
TORAX:______________________________________________________________________________________
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ABDOMEN:___________________________________________________________________________________
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GENITO URINARIO:____________________________________________________________________________
EXTREMIDADES:________________________________________________________________________________
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NEUROLOGICO:________________________________________________________________________________
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PSIQUIATRICO:_________________________________________________________________________________
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DIAGNOSTICO:
SINDROMATICO

IMPRESIÓN DIAGNOSTICA
1:______________________________________2:________________________________________________
3.______________________________________4;________________________________________________
5:______________________________________6.________________________________________________

PRONOSTICO

DIAGNOSTICOS DIFERENCIALES
1:______________________________________2:________________________________________________
3.______________________________________4;________________________________________________
5:______________________________________6.________________________________________________

ORDENES MEDICAS
NO FARMACOLOGICAS
1:______________________________________2:________________________________________________
3.______________________________________4;________________________________________________
5:______________________________________6.________________________________________________
FARMACOLOGICAS
1:______________________________________2:________________________________________________
3.______________________________________4;________________________________________________
5:______________________________________6.________________________________________________
7:______________________________________8:________________________________________________
9.______________________________________10;________________________________________________
PARACLINICOS
1:________________ 2:______________ 3:______________ 4;_______________ 5:___________________
6.______________ 7:________________ 8._______________ 9._______________ 10._______________

NOMBRE Y FIRMA DEL PROFESONAL :______________________________

Sede Santa Marta