Formato de Historia Clínica

No. De Expediente:____________ Fecha:__________

Nombre:____________________________________________ Edad:__________
Fecha de Nacimiento: _______________ Sexo: M___ F___
Domicilio:____________________________________ Teléfono:______________
Ocupación:__________________ E.Civil:___________
Motivo de consulta:__________________________________________________
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ANTECEDENTES PERSONALES NO PATOLÓGICOS
Tabaquismo: Si__ No__ #Al día ____ Alcoholismo: Si__ No__ Frecuencia:_____
Drogas: Si__ No__ Frecuencia:_____________ Actividad física:_______________
_____________ Automedicación: Si___ No ___ Frecuencia:_________________
Farmacodependencia:____________________
HISTORIA DE LA ENFERMEDAD:

Antecedentes Heredofamiliares
SI NO Especifique Signos vitales
Diabetes TA mmHg
Alergias FR x1
HTA TEM °C
Cáncer FC x1
Marca pasos TALL Cm
A
Cardiopatías PESO Kg
Cirugías
Accidentes
Fracturas
Otros
ANTECEDENTES PATOLOGICOS PERSONALES
Enfermedades Respiratorias:
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Enfermedades Cardiovasculares:
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Enfermedades Neurológicas:
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Enfermedades Psicológicas;
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___ Otros Antecedentes ( Cáncer, COVID...)
MOTIVO DE CONSULTA:
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TRATAMIENTOS PREVIOS:
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OBSERVACIONES:
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INSPECCIÓN:
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PALPACIÓN:
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AUSCULTACIÓN:
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ARCOS DE MOVIMIENTO:
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REFLEJOS:
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SENSIBILIDAD:
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DERMATOMAS:
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PRUEBAS CLINICAS:
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MARCHA:
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Imagenología:
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DIAGNÓSTICO MÉDICO:
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PRONOSTICÓ:
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OBJETIVOS:
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TRATAMIENTO FISIOTERAPEUTICO:
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Nombre y firma del fisioterapeuta:

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