HISTORIA CLINICA “HOGAR DE ANCIANOS SAN JOSE”

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1) DATOS ESTADISTICOS
Nombre y Apellidos: ______________________________________________________________________________Edad: __________
Sexo:________Procedencia:_________________Teléfono:___________________Ocupación:____________________________________
Estado Civil: _________________ Dirección: ____________________________Grado de Instrucción:
_____________________________ Fecha de elaboración: ______/______/_______

2) FUENTE DE LA HISTORIA – persona que dá los dactos

a) Propio (a) paciente merece confianza
b) Propio (a) paciente NO merece confianza
c) Parientes, amigos, vecinos, otros los cuales merecen confianza
d) Parientes, amigos, vecinos, otros los cuales NO merecen confianza

3) MOTIVO DE CONSULTA
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4) ENFERMEDAD ACTUAL
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5) ANTECEDENTES PERSONALES
a) No Patológicos
 Vivienda:____________________________________________________________________________________________
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 Alimentación:________________________________________________________________________________________
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 Hábitos y Costumbres:
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b) Patológicos
 Enfermedades de la Niñez: _____________________________________________________________________________
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 Enfermedades de Adulto: ______________________________________________________________________________
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 Hospitalizaciones: ____________________________________________________________________________________
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 Antecedentes Traumáticos: ____________________________________________________________________________
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 Antecedentes Quirúrgicos: _____________________________________________________________________________
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 Alergias: ___________________________________________________________________________________________

6) ANTECEDENTES HEREDO FAMILIARES

 Padre: __________________________________________________________________________________________________
 Madre: __________________________________________________________________________________________________
 Hijos: ___________________________________________________________________________________________________
 Esposo(a): _______________________________________________________________________________________________

7) ANTECEDENTES GINECOOBSTETRICOS
 Menarca: ___________________________Ciclo Menstrual: _____________________________________________________
 Inicio de Vida Sexual Activa: _________________________
 Métodos de Planificación Familiar: ___________________________________________________________________________
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 Fecha de Ultima Menstruación: __________________________ Fecha Probables de Parto: ______________________________
 Gestas: _________ Partos: __________ Abortos: _________ Cesáreas: ___________
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 Menopausia: _______________________________________________________________________
8) REVISION POR SISTEMAS
 SNC: ____________________________________________________________________________________________________
 SCP: ____________________________________________________________________________________________________
 SGI: ____________________________________________________________________________________________________
 SGU: ___________________________________________________________________________________________________
 SME: ___________________________________________________________________________________________________
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9) EXAMEN FISICO GENERAL
Paciente se encuentra en: __________________________________________________________________________________________
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SIGNOS VITALES:
PA: ______/______ FC: __________ FR: __________ Pulso: __________ T: _________ IMC: _________ SPO2: ____________

10) EXAMEN FISICO REGIONAL

 Cabeza: _________________________________________________________________________________________________
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 Ojos: ___________________________________________________________________________________________________
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 Nariz: ___________________________________________________________________________________________________
 Oídos: __________________________________________________________________________________________________
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 Orofaringe: ______________________________________________________________________________________________
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 Cuello: __________________________________________________________________________________________________
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 Tórax: __________________________________________________________________________________________________
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Mamas: _______________________________________________________________________________________________
 Corazón: ________________________________________________________________________________________________
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 Pulmón: ________________________________________________________________________________________________
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 Abdomen: _______________________________________________________________________________________________
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 Genitales: _______________________________________________________________________________________________
 Extremidades: ____________________________________________________________________________________________
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11) IMPRESIÓN DIAGNOSTICA:

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12) CONDUCTA:
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Responsable de la Historia Clínica