HISTORIA CLÍNICA PEDIÁTRICA

Nombre: ______________________________________________________________________ Edad __________________

Fecha de nacimiento: __________________ RUT: ________________ Previsió n: ____________________________
Domicilio: ____________________________________________ ____________ Fono: ______________________________
Fecha de ingreso: ________________________ Hora de ingreso: __________________________________________
Informante: _____________________________________________________________________________________________
Motivo de consulta: ____________________________________________________________________________________
Anamnesis_______________________________________________________________________________________________
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ANTECEDENTES FAMILIARES:
Padre: Nombre__________________________ _ Edad: __________ _ Escolaridad: ____________________________
Ocupació n: __________________________________ Enfermedades: __________________________________________
Madre: Nombre______________________________ Edad: _____________ Escolaridad: _______________________
Ocupació n: _______________________ Enfermedades: ____________________________________________________
Hermanos:______________Edad_________Escolaridad:__________________Enfermedades:_________________
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ANTECEDENTES PERSONALES:
Embarazo ________________________________________________________________________________________________
Parto _______________________Edad gestacional _____________________ Apgar: ____________________________
Antropometría neonatal:
Peso: ______________Talla :___________________ Perímetro craneano:____________________________________
Patología perinatal:
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ALIMENTACIÓN:
Lactancia materna: ___________________________Alimentació n actual:__________________________________
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Suplementos: ___________________________________________________________________________________________
Vacunas: PNI: ______________________________________ No PNI: __________________________________________
Antecedentes mó rbidos: _______________________________________________________________________________
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HISTORIA DE DESARROLLO PSICOMOTOR:
Afirma cabeza _____________-Sonrisa social ____________Coge objetos ________ Se sienta solo ______
Gatea __________ Primeras palabras _________________________Camina solo _____________Frases
_______________________________Control de esfínteres _____________________________________
Escolaridad: Curso, rendimiento y comportamiento: _______________________________________________
EXAMEN FÍSICO GENERAL
ANTROPOMETRÍA.
Peso: _______________________ Talla: ____________________ Perímetro craneano: __________________________
Aspecto general: ________________________________________________________________________________________
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SIGNOS VITALES:
Temperatura: _________ Frecuencia cardíaca: ___________ Frecuencia respiratoria: _________________
Presió n arterial: ______________________________________Saturació n de oxígeno: ________________ FIO2:
___________________________ Glasgow: ____________________
EXAMEN FÍSICO SEGMENTARIO:
Piel________________________________________________________________________________________________________
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Cabeza____________________________________________________________________________________________________
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Cuello:____________________________________________________________________________________________________
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Tó rax_____________________________________________________________________________________________________
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Cardíaco_________________________________________________________________________________________________
Pulmonar________________________________________________________________________________________________
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Abdomen ________________________________________________________________________________________________
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Genitales _________________________________________________________________________________________________
Columna________________________________________________________________________________________________
Extremidades _________________________________________________________________________________________
Neuroló gico y desarrollo psicomotor
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Exámenes realizados
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Hipó tesis diagnó stica
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Problemas y planes
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NOMBRE DEL ALUMNO: ____________________________________________________________

NOMBRE DEL MÉDICO: ______________________________________________________________

FECHA Y HORA: __________________________________________