República Bolivariana de Venezuela

Ministerio del Poder Popular para la Educación

Acarigua Edo-Portuguesa

Clinica 1

Bachiller:

MIC CAMPO LINDO

 Historia Clínica

Nombres y Apellidos: _____________________________________________________________

Edad: _____________
Fecha y lugar de Nacimiento: ____________________________________
Dirección:_______________________________________________________________________
_______________________________________________________________________________

Motivo de consulta: _______________________________________________________________

Historia de enfermedad actual:

_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Antecedentes Patológicos Personales:

_______________________________________________________________________________

Antecedentes Patológicos Familiares:

_______________________________________________________________________________

Reacciones a medicamentos:
_______________________________________________________________________________
_______________________________________________________________________________

Traumatismos:
_______________________________________________________________________________

Transfusiones:
_______________________________________________________________________________

Operaciones
_______________________________________________________________________________

Hábitos tóxicos:
_______________________________________________________________________________
_______________________________________________________________________________
Vacunas:
_______________________________________________________________________________
_______________________________________________________________________________

Condiciones de viviendas:

Piso: tierra: Techo: Cinc Agua: En tubería dentro de la vivienda: _Acueducto:

Cemento: Tejas _Pozo:
Mosaico: Concreto En tubería fuera de la vivienda:-_Rio:
_Pozo
Servicios sanitarios en la vivienda:
Interior uso exclusivo: _Inodora:
_ Letrina

Exterior uso exclusivo:_ Inodoro Baño o ducha en la vivienda: _ Uso exclusivo:

_ Letrina _ Uso de varios
_ Sin baño o ducha:
Sin inodoro o letrina:

Contacto con T.B.C.:

_______________________________________________________________________________

Interrogatorio por Aparatos:

 Aparato Respiratorio:_______________________________________________________
 Aparato Cardiovascular:_____________________________________________________
 Aparato Digestivo:__________________________________________________________
 Aparato Genitourinario:______________________________________________________
 Aparato Ginecologico:_______________________________________________________
 Hemolinfopoyetico:_________________________________________________________
 Nervioso:______________________________________________________________
 Endocrino: :______________________________________________________________
 Otros:____________________________________________________________________

Examen Físico General:

Facie y Marcha:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Mucosas:
_______________________________________________________________________________

Piel:
_______________________________________________________________________________
Fanera:
Pelo: _______________________________________________

Uña:___________________________________________________________________________
______________________________________________________________________________

TCS: : _______________________________________________
Panículo Adiposo: : _____________________________________________

Peso: ______ Talla: : _______ IMC: : __________ Temperatura: : _________

Examen físico Regional:

Cabeza::________________________________________________________________________
_______________________________________________________________________________
Cello::__________________________________________________________________________
_______________________________________________________________________________
Resumen Sindrómico:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Diagnostico Nosológico:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Diagnóstico Diferencial:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Exámenes Complementarios:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Tratamiento:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Conducta a Seguir:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________