HISTORIA CLINICA – TRAUMATOLOGIA

1) ANAMNESIS
I. FILIACIÓN
a. Nombre completo:
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b. Edad:
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c. Sexo:
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d. Raza:
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e. Estado Civil:
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f. Religión:
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g. Nacionalidad:
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h. Ocupación anterior/ actual:
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i. Grado de instrucción:
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j. Domicilio:
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k. Fecha de ingreso:
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l. Lugar de nacimiento:
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m. Lugar de procedencia:
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n. Fecha de elaboración de HCL:
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 o. Historia elaborada por:
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p. Informante:
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II.MOTIVO DE CONSULTA:
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III. ENFERMEDAD ACTUAL:
a. Tiempo de enfermedad:
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b. Forma de inicio:
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c. Curso:
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d. Mecanismo:
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e. Síntomas principales:
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f. Relato cronológico de la enfermedad:
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g. Funciones biológicas
Apetito:
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 Sed:
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Orina:
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Deposiciones:
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Sueño:
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IV. ANTECEDENTES PERSONALES:
a. Personales______________________________________________________
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b. Familiares:
c. Padre
d. Madre
e. Hermanos
f. Hijos
g. Patológicos:
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h. Quirúrgicos:
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i. Alergias:
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V.
VI.