Historia clínica

Fecha de valoración:____________________
1. Ficha de identificación .
Fecha de nacimiento:______________ Entidad de nacimiento:_______________
Escolaridad:______________ Estado civil:_______________
Ocupación:______________ Religión:______________
2. Antecedentes heredofamiliares .
Diabetes,¿Quien?:____________________________________________________
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Hipertension,¿Quien?:_________________________________________________
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cáncer,¿Quien?:______________________________________________________
Tipo:_______________________________________________________________
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Cardiopatías,¿Quien?:_________________________________________________
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Nefropatías,¿Quien?:__________________________________________________
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Malformaciones:______________________________________________________
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Tipo________________________________________________________________
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Otros:_______________________________________________________________
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3. Antecedentes personales no patológicos .
Tabaquismo: Si ___ No ____ ¿cuántos?______ x dia, Años de consumo o
exposición:_____, Ex Fumador: Si ___ No ____, Fumador pasivo: Si ___ No ___
Alcohol: Si ___ No ____ ¿cuanto?:__________, Años de consumo:___________
Ex - Alcohólico y/o ocasional: Si ___ No ___, Alergias: Si___No___,
Especificar:________________________________________________________
Tipo sanguíneo:_____ Rh ____, Vivienda con servicios básicos:Si ___ No ____
Especificar:_______________________________________________________
Farmacodependencia:Si___No____
¿A que?______________________________,Años de consumo:______
4. Antecedentes ginecoobstetricos .
Menarca:____, Ciclos regulares: Si ___ No ___, Ritmo:____
FUM:___/____/____, Polimenorrea: Si___No ____, Hipermenorrea:Si__No____
Dismenorrea: Si___No___, Incapacitante: Si___No___
No. parejas sexuales:______,Fecha de ultima citologia (PAP): ___/___/___,
Resultado:_______________________________________________________
Metodo de planificacion actual:________________________________________
5. Antecedentes personales patológicos .
Enfermedades de la infancia:____________________________________________
Secuelas:____________________________________________________________
Hospitalizaciones previas: Si___ No___,
Especificar:__________________________________________________________
Antecedentes quirúrgicos: Si___ No___,
Especificar:__________________________________________________________
Transfusiones previas: Si___ No___,
Especificar:__________________________________________________________
Fracturas: Si___ No___,
Especificar:__________________________________________________________
Traumatismos: Si___ No___,
Especificar:__________________________________________________________
Otra enfermedad: Si___ No___,
Especificar:__________________________________________________________

6. Motivo de ingreso .
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7. Interrogatorio por aparatos y sistemas .

Respiratorio:_________________________________________________________
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Cardiovascular:_______________________________________________________
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Digestivo:____________________________________________________________
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 Endocrino:___________________________________________________________
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Musculo-Esqueletico:__________________________________________________
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Genetico-Urinario:_____________________________________________________
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Hematopoyetico-Linfatico:_______________________________________________
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Piel y anexos:________________________________________________________
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Neurológico y psiquiátrico:______________________________________________
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Medicamentos actuales:
Nombre Principio activo Presentación Dosis Vía Frecuencia

8. Exploración Clínica .
TA: ___/____ mmHg Fc/pulso:_____ x min, Tem:____C, Peso:____kg, Talla:____mts
Piel y anexos:________________________________________________________
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 Cabeza y 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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Sistema nervioso:_____________________________________________________
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9. Estudios de imagen/ Examenes de laboratorio previos a su ingreso:

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10. Análisis, integración y terapéutica

Diagnósticos diferenciales:
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2.__________________________________________________________________
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Diagnóstico y tratamiento:_______________________________________________
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