HISTORIA CLÍNICA

Datos de Filiación Fecha: _________________

Hora: _________________
Apellidos Nombres Cédula

Edad Sexo Fecha de nacimiento Lugar de nacimiento Nacionalidad

Dirección actual Teléfono

Profesión Ocupación Nivel educativo Estado civil Raza Religión

Datos del acompañante

Motivo de Consulta: ________________________________________________________________________

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Enfermedad Actual: ________________________________________________________________________

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Antecedentes Personales

Fisiológicos

-Nacimiento: ______________________________________________________________________________
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-Crecimiento y maduración: __________________________________________________________________

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-Ginecológicos: ____________________________________________________________________________
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-Obstétricos: _______________________________________________________________________________
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Patológicos

-Inmunización: _____________________________________________________________________________
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-Alérgicos: ________________________________________________________________________________
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-Infectocontagioso: _________________________________________________________________________
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-Traumático: _______________________________________________________________________________
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-Quirúrgico: _______________________________________________________________________________
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-Respiratorio: ______________________________________________________________________________
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-Cardiovascular: ____________________________________________________________________________
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-Digestivo: ________________________________________________________________________________
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-Renal: ___________________________________________________________________________________
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-Endocrinometabólico: _______________________________________________________________________
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-Reumatológico: ____________________________________________________________________________
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-Neurológico: ______________________________________________________________________________
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-Otros: ___________________________________________________________________________________
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De medio (Epidemiológicos)

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Antecedentes Familiares

-Padre: ___________________________________________________________________________________

-Madre: ___________________________________________________________________________________

-Abuelo paterno: ___________________________________________________________________________

-Abuela paterna: ____________________________________________________________________________

-Abuelo materno: ___________________________________________________________________________

-Abuela materna: ___________________________________________________________________________

-Hermanos: _______________________________________________________________________________
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-Hijos: ___________________________________________________________________________________
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 Hábitos Psicobiológicos

-Alimentación: _____________________________________________________________________________
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-Catarsis intestinal: __________________________________________________________________________

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-Diuresis: _________________________________________________________________________________
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-Alcohólico: _______________________________________________________________________________
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-Cafeico: __________________________________________________________________________________
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-Té/Hierbas: _______________________________________________________________________________
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-Tabáquicos/Chimó: _________________________________________________________________________
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-Drogas: __________________________________________________________________________________
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-Medicamentos: ____________________________________________________________________________
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-Sueño: ___________________________________________________________________________________
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-Actividad física: ___________________________________________________________________________

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-Actividad sexual: __________________________________________________________________________

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 Examen Funcional

-General: _________________________________________________________________________________
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-Piel: _____________________________________________________________________________________
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-Cabeza: __________________________________________________________________________________
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-Ojos: ____________________________________________________________________________________
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-Oído: ____________________________________________________________________________________
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-Nariz: ___________________________________________________________________________________
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-Boca: ____________________________________________________________________________________
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-Respiratorio: ______________________________________________________________________________
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-Cardiovascular: ____________________________________________________________________________
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-Digestivo: ________________________________________________________________________________
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-Genitourinario: ____________________________________________________________________________
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-Ginecológico: _____________________________________________________________________________
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-Osteoarticular: ____________________________________________________________________________
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-Neurológico: ______________________________________________________________________________
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 Patobiografía

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 Examen Físico

-Inspección General: ________________________________________________________________________

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-Signos Vitales: TA: __________ FC: __________ FR: __________ Temp: __________ Sat O2: ___________

-Piel y Anexos: _____________________________________________________________________________

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-Cabeza y Cara: ____________________________________________________________________________

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-Ojos: ____________________________________________________________________________________
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-Oído: ____________________________________________________________________________________
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-Nariz: ___________________________________________________________________________________
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-Boca y Faringe: ____________________________________________________________________________

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-Cuello: __________________________________________________________________________________
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-Mama y Axila: ____________________________________________________________________________

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-Tórax y Respiratorio: _______________________________________________________________________

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-Cardiovascular: ____________________________________________________________________________
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-Abdomen: ________________________________________________________________________________
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-Sistema Urinario: __________________________________________________________________________

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-Genitales: ________________________________________________________________________________
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-Recto y Ano: ______________________________________________________________________________

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-Osteoarticular: ____________________________________________________________________________
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-Extremidades: _____________________________________________________________________________
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-Neurológico: ______________________________________________________________________________
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Consideración Diagnóstica
Exámenes Complementarios
Órdenes médicas
Evolución clínica
Epicrisis