Formato de Historia Clínica

Nombre del paciente: _______________Edad: ______ sexo: _____ Estado civil: ______
Ocupación: _______ Lugar de residencia: _____________________
Empresa para la que trabaja: _______ Domicilio particular: ______________________
Teléfono: ____________ RFC_______________ Lugar de Nacimiento: ______________
Fecha de Nacimiento: ______________ Correo electrónico: ______________________

Signos Vitales. T.A._______ F.C._____ F. R.____ Temp______ SAT O2____

Peso: ________ Talla: ________ IMC: __________

Motivo de Consulta_________________________________________________

Antecedentes Personales Patológicos

Cardiovasculares____Pulmonares____Digestivos______Diabetes___
Renales______Quirúrgicos_____Alérgicos_____Transfusiones_____
Medicamentos____________________________________________

Antecedentes Personales No Patológicos

Alcohol: _________ Tabaquismo: _______
Toxicomanías: ________ Otros: ______________________________

Antecedentes Familiares:
Madre: ____________________Padre: _____________Hermanos: ____________
Hijos_________________Conyuge_______________________________________

Padecimiento actual
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Exploración física.
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Estudios complementarios:
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Impresión Diagnostica:
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Tratamiento:
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EVOLUCIÓN Y SEGUIMIENTO DE TRATAMIENTO:
Dr.: ________________________
FECHA: (___/___/___) Cedula: _____________________
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