HISTORIA CLINICA

FECHA: ___________________
PACIENTE:____________________________________ F. NAC.: __/__/__ EDAD: ____
MOTIVO DE CONSULTA: _________________________________________________
ANTECEDENTES PERSONALES
VACUNAS: _______________________________ COVID-19 ____________________
ENFERMEDADES CRÓNICAS:_______________________TRAUMATISMO:__________
INTERVENCIONES QUIRURGICAS: _________________________________________
ULTIMO TRATAMIENTO ODONTOLOGICO:__________________________________
HÁBITOS PERNICIOSOS: _________________________________________________
ALERGIAS:_________________________ POSTURA:___________________________
MAPEO DEL DOLOR:___________________________________CLASE MOLAR:_____
RESPIRADOR BUCAL: ________________ BRUXISMO:__________________________
MUCOSA ORAL:________________________________________________________
ORGANOS DENTARIOS:_________________________________________________
____________________________________________________________________-
ODONTOGRAMA

DIAGNÓSTICO
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
PLAN DE TRATAMIENTO
_________________________________________________________
_________________________________________________________ _________________
_________________________________________________________ FIRMA:
_________________________________________________________