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formato-de-historia-clinica

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 HISTORIA CLINICA
FICHA DE IDENTIFICACION

Nombre ________________________________________ Edad ____ Sexo ______

Estado Civil _____ Ocupación _________ Procedencia __________ Raza ________

Religión __________ Lugar de Nacimiento y Residencia ______________________

Domicilio____________________________________________________________

Fecha, hora y persona que elabora la Historia Clínica _______________________

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MOTIVO DE CONSULTA

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ANTECEDENTES

Antecedentes heredofamiliares __________________________________________

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Antecedentes personales no patológicos __________________________________

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Antecedentes gineco-obstétricos ________________________________________

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Antecedentes personales patológicos _____________________________________

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PADECIMIENTO ACTUAL

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INTERROGATORIO POR APARATOS Y SISTEMAS

Síntomas generales ________________________________________________

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Aparato digestivo __________________________________________________

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Aparato cardiovascular _____________________________________________

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Aparato respiratorio ________________________________________________

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Sistema urinario ___________________________________________________

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Aparato genital ____________________________________________________

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Sistema hematológico ______________________________________________

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Sistema endócrino _________________________________________________
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Sistema musculo-esquelético ________________________________________

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Sistema nervioso ___________________________________________________

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Psicosomático _____________________________________________________
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EXPLORACION FISICA

Signos Vitales

T/A _______ FC ______ FR ______ Temperatura ______ Talla ______ Peso ____
I.M.C.______

Inspección general (Habitus exterior) ________________________________

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Cabeza y cara ______________________________________________________

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Ojos ______________________________________________________________
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Nariz y senos faciales _______________________________________________

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Boca ______________________________________________________________
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Faringe y laringe ___________________________________________________

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Oídos _____________________________________________________________
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Cuello _____________________________________________________________
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Tórax y pulmones __________________________________________________

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Tórax cardíaco (región precordial) ___________________________________

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Glándula mamaria __________________________________________________

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Abdomen __________________________________________________________
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Neurológico _______________________________________________________
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Extremidades superiores ____________________________________________

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Extremidades inferiores ____________________________________________

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Genitales __________________________________________________________
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Tacto rectal ________________________________________________________

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