Historia Clínica

DATOS PERSONALES

Nombre: Estado Civil:

Edad: Sexo:
Fecha: Fecha de nacimiento:
Religión: Raza:
Ocupación: Dirección:
Escolaridad: Acompañante:

MOTIVO DE CONSULTA:
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HISTORIA DE LA ENFERMEDAD ACTUAL:
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Antecedentes personales patológicos:

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Antecedentes personales no patológicos:

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Antecedentes medicamentosos:
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Antecedentes en la infancia:
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Antecedentes heredo familiares:

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Antecedentes alérgicos:
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Antecedentes quirúrgicos:
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DESCRIPCIÓN DE LA VIVIENDA:
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HÁBITOS TOXICO:
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Antecedente Gineco-Obstétricos:
FUM: ________ Menarca: _________ 1 coito: ____________ Anticonceptivos: ________
Ciclo: ________ N. Parejas: ________ Menopausia: ________PAP: ________
E: ___P: ___C: ____A: ____

EXAMEN FÍSICO:
TA: _______ FC: _______TEMP: _______PESO: _______TALLA: _______

INSPECCION GENERAL:
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Cabeza y cuello:
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Tórax:
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Corazón:
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Pulmones:
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Abdomen:
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Extremidades:
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Neurológico:
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Consideraciones de diagnóstico:
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