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HISTORIA CLINICA GENERAL INDIVIDUAL

NOMBRE Y APELLIDOS: __________________________________________________________________

EDAD:_________________ SEXO:_______________________ RAZA:_________________________
CEDULA DE IDENTIDAD:____________________ OCUPACION:__________________________________
DIRECCION:_________________________________________________ TELEFONO:_________________
ESTADO:____________MUNICIPIO: ____________ASIC: _______________CONSULTORIO:___________

CONSULTA

FECHA:______/_____/______ HORA:_____________
MOTIVO DE CONSULTA:_________________________________________________________________

HISTORIA DE LA ENFERMEDAD ACTUAL:

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ANTECEDENTES PATOLOGICOS PERSONALES:________________________________________________
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ANTECEDENTES PATOLOGICOS FAMILIARES:_________________________________________________

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ANTECEDENTES QUIRURGICOS: __________________________________________________________

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ANTECEDENTES OBSTETRICOS: __________________________________________________________

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HABITOS TOXICOS: _____________________________________________________________________

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ALERGIA A MEDICAMENTOS: _____________________________________________________________

TRANSFUSIONES: ______________________________________________________________________

TRAUMATISMOS: ______________________________________________________________________

VACUNACION: _________________________________________________________________________
 HISTORIA PSICOSOCIAL
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 INTERROGATORIO POR SISTEMAS O APARATOS

APARATO RESPIRATORIO:________________________________________________________________
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APARATO CARDIOVASCULAR:_____________________________________________________________
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APARATO DIGESTIVO: ___________________________________________________________________

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APARATO GENITOURINARIO: _____________________________________________________________

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SISTEMA HEMOLINFOPOYETICO:__________________________________________________________
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SISTEMA NERVIOSO:____________________________________________________________________
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SISTEMA ENDOCRINO:___________________________________________________________________
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SISTEMA OSTEOMIOARTICULAR:__________________________________________________________
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 EXAMEN FISICO GENERAL

PESO:_________ TALLA:_________ IMC:_________________ TEMPERATURA:________

FC:_______ TA:_________ FR:______ PULSO:________
VALORACION NUTRICIONAL: _____________________________________________________________
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MARCHA: ____________________________________________________________________________
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BIOTIPO: _____________________________________________________________________________
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ACTITUD: _____________________________________________________________________________
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FACIES: ______________________________________________________________________________
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PIEL: _________________________________________________________________________________
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MUCOSAS: ____________________________________________________________________________
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FANERAS: ____________________________________________________________________________
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TEJIDO CELULAR SUBCUTANEO: ___________________________________________________________
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PANICULO ADIPOSO: ___________________________________________________________________
 EXAMEN FISICO REGIONAL

CRANEO:______________________________________________________________________________
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CARA: _______________________________________________________________________________
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CUELLO: _____________________________________________________________________________
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TIROIDES: ____________________________________________________________________________
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GANGLIOS LINFATICOS DE CABEZA Y CUELLO: ________________________________________________
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TORAX: ______________________________________________________________________________
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MAMAS: _____________________________________________________________________________
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AXILAS: ______________________________________________________________________________
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ABDOMEN: ___________________________________________________________________________
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COLUMNA VERTEBRAL: _________________________________________________________________
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EXTREMIDADES: _______________________________________________________________________
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 EXAMEN FISICO POR SISTEMAS

SISTEMA RESPIRATORIO:_________________________________________________________________
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SISTEMA CARDIOVASCULAR:______________________________________________________________
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SISTEMA DIGESTIVO: ___________________________________________________________________

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SISTEMA GENITOURINARIO: ______________________________________________________________

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SISTEMA HEMOLINFOPOYETICO:__________________________________________________________
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SISTEMA NERVIOSO
NIVEL DE CONCIENCIA: __________________________________________________________________
ORIENTACION: ________________________________________________________________________
MEMORIA: ___________________________________________________________________________
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LENGUAJE: ___________________________________________________________________________
TAXIA ESTATICA
ROMBERG SIMPLE:_____________________________________________________________________
ROMBERG SENSIBILIZADO:_______________________________________________________________
TAXIA DINAMICA:______________________________________________________________________
PRAXIA: ______________________________________________________________________________
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MOTILIDAD: __________________________________________________________________________
TONO MUSCULAR:______________________________________________________________________
REFLECTIVIDAD: _______________________________________________________________________
SENSIBILIDAD SUPERFICIAL:______________________________________________________________
SENSIBILIDAD PROFUNDA:_______________________________________________________________

PARES CRANEALES
PAR I:________________________________________________________________________________
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PAR V:________________________________________________________________________________
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PAR VII:______________________________________________________________________________
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PAR VIII:______________________________________________________________________________
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PAR IX:_______________________________________________________________________________
PAR X:________________________________________________________________________________
PAR XI:_______________________________________________________________________________
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PAR XII:______________________________________________________________________________
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IMPRESIÓN DIAGNOSTICA:
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RESUMEN SINDROMICO:
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DIAGNOSTICO DIFERENCIAL:
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COMPLEMENTARIOS INDICADOS:
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INDICACIONES MEDICAS:
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FECHA DE PROXIMA CONSULTA:______/_____/______

FIRMA Y SELLO:________________