HISTORIA CLINICA

FECHA DE ELABORACIÓN HORA DE ELABORACIÓN TIPO DE INTERROGACIÓN No. EXPEDIENTE

DIRECTO INDIRECTO

I. FICHA DE IDENTIFICACIÓN
NOMBRE DEL PACIENTE (APELLIDO PATERNO MATERNO Y NOMBRE EDAD GÉNERO
MASC FEM
FECHA DE NACIMIENTO OCUPACIÓN DEL PACIENTE PERTENECE A ALGUNA ETNIA SI NO CUAL ESTADO CIVIL
HABLANTE DE UNA LENGUA SI NO
DOMICILIO RELIGION

NOMBRE DEL RESPONSABLE

PARENTESCO CON EL PACIENTE TELÉFONO DEL RESPONSABLE: ______________________________

TELEFONO DEL PACIENTE: __________________________________
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ll. ANTECEDENTES HEREDOFAMILIARES
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llI. ANTECEDENTES PERSONALES NO PATÓLOGICOS
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IV. ANTECEDENTES PERSONALES PATOLÓGICOS (USO Y DEPENDENCIA DE TABACO, ALCOHOL Y SUSTANCIAS PSICOACTIVAS )
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ANTECEDENTES GINECO-OBSTÉTRICOS
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V. PADECIMIENTO ACTUAL (TERAPEUTICA EMPLEADA: CONVENCIONAL, ALTERNATIVOS Y TRADICIONALES)
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VI. INTERROGATORIO POR APARATOS Y SISTEMAS

CARDIOVASCULAR________________________________________________________________________________________________________________________
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RESPIRATORIO___________________________________________________________________________________________________________________________
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GASTROINTESTINAL_______________________________________________________________________________________________________________________
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GENITOURINARIO________________________________________________________________________________________________________________________
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HÉMATICO Y LINFÁTICO ___________________________________________________________________________________________________________________
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ENDÓCRINO_____________________________________________________________________________________________________________________________
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NERVIOSO______________________________________________________________________________________________________________________________
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MUSCULO ESQUELETICO___________________________________________________________________________________________________________________
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PIEL, MUCOSAS Y ANEXOS _________________________________________________________________________________________________________________

GERIATRÍA CLÍNICA
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VII. EXPLORACIÓN FÍSICA

SIGNOS VITALES
T/A TEMPERATURA FREC.CARDIACA FREC. RESPIRATORIA PESO TALLA IMC

HABITUS EXTERIOR_______________________________________________________________________________________________________________________
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CABEZA_________________________________________________________________________________________________________________________________
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CUELLO:________________________________________________________________________________________________________________________________
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TORAX:_________________________________________________________________________________________________________________________________
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ABDOMEN:______________________________________________________________________________________________________________________________
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GENITALES:______________________________________________________________________________________________________________________________
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EXTREMIDADES:__________________________________________________________________________________________________________________________
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PIEL:___________________________________________________________________________________________________________________________________
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VIII. RESULTADOS PREVIOS Y ACTUALES DE LABORATORIO, GABINETE Y OTROS:
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X. DIAGNÓSTICOS O PROBLEMAS CLÍNICOS:
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XI.- PRONÓSTICO________________________________________________________________________________________________________________________
IX. INDICACIÓN TERAPÉUTICA
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NOMBRE COMPLETO, CEDULA PROFESIONAL Y FIRMA DEL PROFESIONAL DEL ÁREA DE SALUD

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GERIATRÍA CLÍNICA