Historia clínica

Ficha de identificación

Nombre: ________________________________________________________________________

Número de registro: _______________________ Sexo: __________ Fecha: __________

Edad: ______________ Cuarto: _____________ Servicio: ___________________

Ocupación: ________________ Nacionalidad: _______________ Religión: ______________

Domicilio: _______________________________________________________________________

Teléfono de emergencia: ___________________________________________________________

Persona a quien contactar en caso de emergencia: _______________________________________

Parentesco: ______________________________________________________________________

Motivo de consulta: _______________________________________________________________

Antecedentes Personales Patológicos.

Cardiovasculares: _________________________________________________________________

Pulmonares: _____________________________________________________________________

Digestivos: _______________________________________________________________________

Diabetes: ________________________________________________________________________

Renales: _________________________________________________________________________

Quirúrgicos: ______________________________________________________________________

Alérgicos: ________________________________________________________________________

Transfusiones: ____________________________________________________________________

Medicamentos: Si __________ No _________

Especifique: ______________________________________________________________________
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Otros: ___________________________________________________________________________
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Antecedentes Personales No Patológicos

Alimentación: ____________________________________________________________________

No. de comidas al día: ______________________________________________________________

Cantidad: ________________________________________________________________________

Calidad: _________________________________________________________________________

Litros de agua al día: _______________________________________________________________

Casa Propia: Si: __________ No: __________

Habitaciones: _____________________________________________________________________

Piso: ____________________________________________________________________________

Ventilación: ______________________________________________________________________

Iluminación: ______________________________________________________________________

Agua potable: ____________________________________________________________________

Drenaje: _________________________________________________________________________

Gas: ____________________________________________________________________________

Ambiente: _______________________________________________________________________

En que duerme: ___________________________________________________________________

Promiscuidad: ____________________________________________________________________

Hacinamiento: ____________________________________________________________________

Fecalismo: _______________________________________________________________________

Hábitos higiénicos

Baño: Diario: ________ Cada 2 días: _________Cada 3er día: ________ Otro: ___________

Lavado de manos: _________________________________________________________________

Cambio de ropa: __________________________________________________________________

Higiene bucal: ____________________________________________________________________

Actividad Física: ___________________________________________________________________

Actividad física y actividades de ocio: __________________________________________________

Alcohol: Si __________ No __________

¿Cuándo inició? _________________________

¿Cuántas copas se toma a la semana? _________________________________________________

Tabaquismo: Si __________ No __________

¿Cuándo inició? _________________________

Número de cigarrillos al día ___________________ Índice tabáquico _____________________

Drogas: Si __________ No __________

¿Cuándo inició? _________________________

Inmunizaciones: __________________________________________________________________

Antecedentes Familiares

Padre: Vivo Si_____ No_____

Enfermedades:____________________________________________________________________
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Madre: Viva Si_____ No_____

Enfermedades:____________________________________________________________________
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Hermanos: ¿Cuántos? _____ Vivos_____ Fallecidos_____

Enfermedades:____________________________________________________________________
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Otros:___________________________________________________________________________
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Antecedentes Gineco-obstétricos:

Menarquia_______________ Ritmo_______________ F.U.M._______________

G_____ P_____ A_____ C_____ I.V.S.A_______________

Parejas sexuales________

Uso de métodos anticonceptivos: Si_____ No_____

¿Cuáles? _________________________________________________________________________
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Padecimiento actual

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Datos negativos relevantes

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Datos positivos relevantes

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Interrogatorio por Aparatos y Sistemas (I.P.A.S.)

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Exploración física

Signos vitales

T.A. __________ F.C. __________ F.R. __________ Temp. __________

SatO2 ________

Peso: ______________ Talla: _______________ IMC _______________

Cabeza y Cuello

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Tórax

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Abdomen

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Extremidades

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Neurológico y estado mental

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Estudios de imagen

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Otros

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