HISTORIA CLINICA

Fecha de primera sesión: ____________________ número de sesión: ___________________

I.- FICHA DE IDENTIFICACION

Nombre: _________________________________________________________________________

Edad: ______ genero: ______ escolaridad: _____________ Ocupación: _________________

teléfono: _________________

II.- ANTECEDENTES PERSONALES NO PATOLOGICOS

Dieta___________________________________________________________________________

Ejercicio y recreación_____________________toxicomanias:______________________________

Sueño y descanso: ________________número de micciones y evacuaciones: _________________

Mascotas______ Viajes__________ servicios__________________________________________

Ambiente laboral: _____________________ exposición a tóxicos: _________________________

III.- ANTECEDENTRS HEREDOFAMILIARES

Diabetes___________________________ Hipertensión__________________________________

cardiopatías___________________ cáncer____________________ Otra____________________

IV.- ANTECEDENTES PERSONALES PATOLOGICOS

Enfermedades importantes: ____________________________ Alergias: ___________________

Traumatismo: ________________ cirugías, transfusiones: ______________________________

Crónico degenerativas: __________________________ ETS: __________________

Alteraciones coagulación, circulación: ______________________________________________

Piel:___________________________ Infecciones graves: _________________________________

Medicamentos que toma actualmente: ________________________________________________

Ginecológicos: menarca_______ ritmo__________ FUM________ características flujo__________

_______________________ G____ P_____ A_____ C____ FUP______ Papanicolao____________

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V.- PERFIL DE EMOCIONES (1 poco, 2 medio, 3 mucho)

IRA ________ ALEGRIA_______ PREOCUPACION _________ ANSIEDAD ________ TRISTEZA ______

CORAJE _________ PENA______ TEMOR_______ OTRA_____________

VI.- PADECIMIENTO ACTUAL

Signos y síntomas, cuando empezó, como ha evolucionado, que lo mejora y lo empeora: _______

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Tratamientos para el padecimiento: __________________________________________________

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VII.- EXPLORACION FISICA

Habitus exterior: ______________________________________________MARCHA:____________

Actitud: ____________________________________FC: __________TA_____________________

Temperatura: ___________ Facies_________________________ piel _____________________

ojos _________________________labios ______________________________________________

lengua (color, constitución, forma, saburra, humedad) ____________________________________
pulso (amplitud, fuerza, profundidad, ritmo, velocidad, forma):

Derecho (P B PC) __________________________________________________________________

Izquierdo (C H R) __________________________________________________________________

Tórax ____________________ abdomen___________________ extremidades________________

VIII.- ESTUDIO DE LABORATORIO Y GABINETE

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IX.- DIAGNOSTICO

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X.- TRATAMIENTO

Principios terapéuticos y puntos de selección __________________________________________

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NOTA: reacciones adversas como somnolencia, cansancio, mareo. Después del TX o durante el.

Firma del paciente: _______________________ Firma del Terapeuta: _____________________

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XI.- NOTA DE EVOLUCION

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