HISTORIA CLINICA

FECHA: / /2019
DATOS DE IDENTIFICACION DEL PACIENTE:
Primer apellido: ___________________ Segundo apellido: _________________
Nombre: ___________________________ Edad: ______ Sexo: ___ Raza: _____
Fecha de nacimiento: __________ Lugar de nacimiento: __________
Estado civil: ___________ Ocupación: ______________
Dirección:
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Teléfono:_______________________ En caso de emergencia
avisar:______________________________________________________________
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MOTIVO DE CONSULTA
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HISTORIA DE LA ENFERMEDAD ACTUAL:

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DX:
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ANTECEDENTES FAMILIARES:
Madre: ___________________________________________________________
Padre: ____________________________________________________________
Hermanos(as): ______________________________________________________
ANTECEDENTES PERSONALES:
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Enfermedades eruptivas de la infancia:

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Reacción a medicamentos o alimentos:
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Transfusiones sanguíneas previas:
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Operaciones:
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Traumatismos:
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Hábitos tóxicos:
Café: _________
Tabaco: __________
Alcohol: _________
Drogas: _________

Ginecológico:
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 HISTORIA PSICOSOCIAL

VIVIENDA
PROPIA: ____ ALQUILADA: _____ INVACION: ___
Piso: __ Techo: ___
Tierra___ Guano__
Cemento___ Zinc__
Mosaico___ Tejas__
Concreto__

SERVICIOS PUBLICOS:
Agua: ___
Electricidad: ___
Gas: ___
Red de cloacas: ___
Aseo: ___
Servicios sanitarios en la vivienda:
Inodoro: ___
Letrina: ___
Ducha en la vivienda: __________
ANIMALES DOMÉSTICOS:
Perros__ Gatos__ Aves___ Otros__

EXAMEN FUNCIONAL
Genera_____________________________________________________________
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Ojos_______________________________________________________________
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Nariz_______________________________________________________________
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Boca_______________________________________________________________
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Oído_______________________________________________________________
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Cuello______________________________________________________________
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Tórax______________________________________________________________
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Cardiovascular_______________________________________________________
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Respiratorio_________________________________________________________
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Abdomen/
Digestivo____________________________________________________________
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Genitourinario________________________________________________________
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Neurológico_________________________________________________________
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 EXAMEN FISICO
PESO: _____
TALLA: ____
TEMPERATURA: _______
IMC: ____
Signos Vitales:
T.A: ______
F.C: _____
F.R: _____

General:
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CABEZA

Cráneo___________________________________________________________________
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CARA

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Nariz_______________________________________________________________
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Oído_______________________________________________________________
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Boca_______________________________________________________________
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Cuello______________________________________________________________
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Tórax____________________________________________________________________
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 ORDENES MEDICAS
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