FACULTAD DE MEDICINA UNIVERSIDAD COOPERATIVA DE SEMIOLOGIA

COLOMBIA
IPS:_____________________ CIUDAD: ______________
FECHA Y HORA: ______________________
HISTORIA CLINICA _____________________ No. ___________________
MODALIDAD DEL SERVICIO : ________________
IDENTIFICACION
NOMBRES:________________________________APELLIDOS:_______________________________
TIPO DE IDENTIFICACION: _______________ No. IDENTIFICACION: ___________________________
EDAD: _____________ GENERO:_____________ESTADO CIVIL;_____________________
OCUPACION:__________
GRUPO ETNICO: ___________________ RELIGION: ______________ ESCOLARIDAD: ________
NATURAL:_____________________ RESIDENCIA:_______________________
PROCEDENCIA:________
DIRECCION: ________________________________ TELEFONO:________________________
REGIMEN EN EL SGSS:________________________
ENTIDAD :____________________ TIPO AFILIADO: __________
ACOMPAÑANTE:________________________ RESPONSABLE:_______________________________
DIRECCION TELEFONO RESPONSABLE:_______________________ PARENTESCO RESPONSABLE: _________________
CAUSA EXTERNA:_______________________ FINALIDAD:____________________________________

MOTIVO DE CONSULTA:____________________________________
ENFERMEDAD ACTUAL;
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
ANTECEDENTES PERSONALES
ANTECEDENTES PATOLOGICOS:__________________________________________________________________
_______________________________________________________________________________________________
ANTECEDENTES FARMACOLOGICOS: _________________________________________________________________
_______________________________________________________________________________________________
ANTECEDENTES QUIRURGICOS: ____________________________________________________
_______________________________________________________________________________________________

Sede Santa Marta

FACULTAD DE MEDICINA UNIVERSIDAD COOPERATIVA DE SEMIOLOGIA
COLOMBIA
ANTECEDENTES INMUNOLOGICOS :__________________________________________________
_______________________________________________________________________________________________
ANTECEDENTES ALERGICOS:_____________________________________________________________________
ANTECEDENTES TRAUMATICOS:_______________________________________________________________
ANTECEDENTES TRANSFUSIONALES Y HEMOCLASIFICACIÓN:________________________________________
HOSPITALIZACIONES:_____________________________________________________________________
ANTECEDENTES PSICO SOCIALES
ANTECEDENTES OCUPACIONALES:________________________________________________________________
_______________________________________________________________________________________________
HABITOS DE VIDA: SALUDABLES:____________________________________________________________
NO SALUDABLES. ______________________________________________________________________
ANTECEDENTES OBSTETRICOS;
M: _________ FUM;______________CICLOS:____________
DURACION:_________
INICIO VIDA SEXUAL:_____
G: ____ p:_____ A:______ C:______ MORTINATOS:___________ HIJOS VIVOS:__________
PLANIFICACION:_____________________ F ULTIMA CITOLOGIA:_____________ RESULTADO:_____________

ANTECEDENTES FAMILIARES
PADRE:____________________________________ MADRE:_______________________________
HERMANOS_______________ HIJOS:_________________
OTROS:__________________________________________________________________________________

REVISION POR SISTEMAS

SINTOMAS GENERALES __________________________________________________________________________

____________________________________________________________________________________________
PIEL Y ANEXOS __________________________________________________________________________
_______________________________________________________________________________________________
CABEZA, CARA, CUELLO __________________________________________________________________________
_______________________________________________________________________________________________
ORGANO DE LOS SENTIDOS :________________________
_________________________________________________________
_______________________________________________________________________________________________
BOCA Y FARINGE _________________________________________________________________________
_______________________________________________________________________________________________
CARDIO PULMONAR _________________________________________________________________________
_______________________________________________________________________________________________
ABDOMEN ________________________________________________________________________
_______________________________________________________________________________________________
GENITOURINARIO _________________________________________________________________________
_______________________________________________________________________________________________
LOCOMOTOR EXTREMIDADES:_____________________________
_________________________________________________________
__________________________________________________________________________________________
NEUROPSIQUIATRICO _________________________________________________________________________
_______________________________________________________________________________________________

EXAMEN FISICO
SIGNOS VITALES TA: ______________ PULSO:__________ TEMP:______________
F.RESP.________________

Sede Santa Marta

FACULTAD DE MEDICINA UNIVERSIDAD COOPERATIVA DE SEMIOLOGIA
COLOMBIA
SATURACION O2:_______
PESO:__________ TALLA:_________ IMC:_______________

ESTADO GENERAL:___________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
PIEL Y ANEXOS ;___________________________________________________________________________
_______________________________________________________________________________________________
CABEZA, CRANEO, CARA, CUELLO :____________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
OJOS: ______________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
NARIZ OLFATO_________________________________________________________________________________
_______________________________________________________________________________________________
OIDOS _______________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
BOCA:_______________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
TORAX:______________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
ABDOMEN:___________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
GENITO URINARIO:____________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
EXTREMIDADES:________________________________________________________________________________
_______________________________________________________________________________________________

Sede Santa Marta

FACULTAD DE MEDICINA UNIVERSIDAD COOPERATIVA DE SEMIOLOGIA
COLOMBIA
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
NEUROLOGICO:________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
PSIQUIATRICO:_________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

DIAGNOSTICO:
1:______________________________________2:________________________________________________
3.______________________________________4;________________________________________________
5:______________________________________6.________________________________________________

PRONOSTICO
______________________
ORDENES MEDICAS
NO FARMACOLOGICAS
1:______________________________________2:________________________________________________
3.______________________________________4;________________________________________________
5:______________________________________6.________________________________________________
FARMACOLOGICAS
1:______________________________________2:________________________________________________
3.______________________________________4;________________________________________________
5:______________________________________6.________________________________________________
7:______________________________________8:________________________________________________
9.______________________________________10;________________________________________________
PARACLINICOS
1:________________ 2:______________ 3:______________ 4;_______________
5:___________________
6.______________ 7:________________ 8._______________ 9._______________
10._______________

NOMBRE Y FIRMA DEL PROFESONAL :______________________________ REG. MED. ______________

Sede Santa Marta