Mais conteúdo relacionado
Semelhante a Formato de Historia Clinica (20)
Formato de Historia Clinica
- 1. Programa de Enseñanza Clínica Complementaria
HISTORIA CLINICA
FICHA DE IDENTIFICACION:
Nombre:____________________________________________________Edad:___________Sexo:________
Ocupación:________________Estado Civil:_____________Nacionalidad:____________________________
Residencia_____________________Escolaridad:________________________Religión:_________________
Servicio:________________________Cama:________ No. Expediente:______________________________
ANTECEDENTES HEREDOFAMILIARES:
Padres: ........................Vivos: ................................Fallecidos:..............................................................................
…………………………
……Causas:..................................................................................
Hermanos:....................Vivos:................................Fallecidos:..............................................................................
…………………………
…… Causas:..................................................................................
Hijos:............................Vivos:..................................Fallecidos:............................................................................
Causas:……............................................................................
Diabetes Mellitus tipo 2 SI ⃝ NO ⃝ __________________________________________________________
Hipertensión Arterial
SI ⃝ NO ⃝ __________________________________________________________
Tuberculosis
SI ⃝ NO ⃝ __________________________________________________________
Cáncer
SI ⃝ NO ⃝ __________________________________________________________
Otras (especificar)
SI ⃝ NO ⃝ __________________________________________________________
ANTECEDENTES PERSONALES NO PATOLOGICOS:
1) Hábitos Tóxicos:
Alcohol: __________________________Tabaco:_________________________Drogas:_________________
2) Fisiológicos:
Alimentación:____________________________________________________________________________
Dipsia:__________________________________________________________________________________
Diuresis: ________________________________________________________________________________
Catarsis:_________________________________________________________________________________
Somnia:_________________________________________________________________________________
Otros:__________________________________________________________________________________
ANTECEDENTES PERSONALES PATOLOGICOS:
- 2. Infancia:_________________________________________________________________________________
Adulto:__________________________________________________________________________________
Diabetes Mellitus tipo 2 SI ⃝ NO ⃝ __________________________________________________________
Hipertensión Arterial
SI ⃝ NO ⃝ __________________________________________________________
Tuberculosis
SI ⃝ NO ⃝ __________________________________________________________
Cáncer
SI ⃝ NO ⃝ __________________________________________________________
Otras (especificar)
SI ⃝ NO ⃝ __________________________________________________________
Quirúrgicos:______________________________________________________________________________
Traumatológicos:_________________________________________________________________________
Alérgicos: _______________________________________________________________________________
Otros: __________________________________________________________________________________
GINECO-OBSTÉTRICOS:
FUM:
/
/
FPP:
/
/
EDAD GESTACIONAL:
semanas.
Menarca:_______RM (Rit. Menstr)____/___ IRS____Nº de parejas____Flujo genital____________________
Gestas:.............Partos:.............Cesáreas:...............Abortos: ____________ Anticonceptivos: SI ⃝ NO ⃝
Tipo: ______________________ Tiempo: __________Última toma: ________________________________
Cirugías ginecológicas (especificar)___________________________________________________________
Otros: __________________________________________________________________________________
PADECIMIENTO ACTUAL
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
- 3. INTERROGATORIO POR APARATOS Y SISTEMAS
Aparato respiratorio:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Aparato digestivo:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Aparato cardiovascular:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Aparato renal y urinario:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Aparato genital:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Sistema endocrino:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Sistema hematopoyético y linfático:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Piel y anexos:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Musculo esquelético:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Sistema nervioso:
________________________________________________________________________________________
- 4. ________________________________________________________________________________________
________________________________________________________________________________________
Órganos de los sentidos:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Síntomas generales:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
EXPLORACIÓN FÍSICA:
Impresión General: _______________________________________________________________________
Signos Vitales: FC__________TA:_________FR: _______PULSO:____________ TEMPERATURA: _________
Peso actual: ________Talla: __________BMI:___________
Inspección general:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Cabeza:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Cuello:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Tórax:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________