HISTORIA CLÍNICA.

Fecha: __________________________ Hora: _______________ Expediente: ______________

1) IDENTIFICACIÓN DEL PACIENTE.

Nombre: __________________________________________________________________________

Edad: ______ Sexo: M ___ F ___ Edo. Civil: S__ C __ V __ D __ UL __ Religion: _________

Lugar de nacimiento: __________________________ Fecha de nacimiento: __________________

Ocupación: _____________________________ Escolaridad: _______________________________

Dirección: _________________________________________________________________________

Teléfono celular: _____________ Teléfono de casa: ______________ Email: ________________

Responsable legal: ______________________________ Parentesco: ________________________

Referido por: _________________________________________________

Motivo de la consulta: _______________________________________________________________

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2) ANTECEDENTES FAMILIARES.

__ Diabetes __ Obesidad __ Alcoholismo

__ Enfermedad mental __ Suicidio __ Tuberculosis

__ Cardiopatías __ Hipertensión Arterial __ Convulsiones

__ Anemias __ Enfermedades reumáticas __ Otras

Describir las positivas: ______________________________________________________________

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 3) ANTECEDENTES PERSONALES NO PATOLÓGICO.

Uso de:

__ Tabaco __ Drogas __ Alcohol __ Solventes __ Trauma

Describir los positivos: ____________________________________________________________

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Inmunizaciones: __________________________________________________________________

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Alimentación habitual:

Desayuno: ____________________________________________________________________

Comida: ______________________________________________________________________

Cena: ________________________________________________________________________

Colaciones: ___________________________________________________________________

4) ANTECEDENTES PERSONALES PATOLÓGICOS

__ Amigdalitis __ Paludismo __ Dengue __ Hepatitis

__ Enf. Venéreas __ Traumatismos __ F. reumática __ Infarto miocárdico

__ Parasitosis __ Neoplasias __ Farmacodependencia __ Cirugías

__ Alcoholismo __ Otros

Describir los positivos:

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 5) PADECIMIENTO ACTUAL

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6) EXPLORACIÓN FÍSICA

Peso actual: ________kg. Peso ideal: ________kg. Perímetro cefálico: ________

Estatura: ____________m, Pulso: ____________ Respiración: ______________

Temperatura: ______________ TA: ____________mmhg.

Lateralidad manual: __ Z __ D __A

Exploración general:

Cabeza: ________________________________________________________________________

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Cuello: _________________________________________________________________________

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Tórax: _________________________________________________________________________

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Cara posterior de tórax y región glútea: ______________________________________________

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Extremidades: ___________________________________________________________________

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Tegumentario: ___________________________________________________________________

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SENSIBILIDAD

(LESIONES MEDULARES)

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 SENSIBILIDAD DE CRÁNEO Y CARA

RESUMEN DE DATOS CLÍNICOS

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 7) NOTAS DE EVOLUCIÓN TERAPÉUTICA

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