HISTORIA CLINICA

Nombre:_____________________________________________

Edad:_____ Fecha ___ ___ ___ H.C. N°:______

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Sexo M_ F_ Casado_ Soltero_ Viudo_ Separado_ Union de hecho_
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Fecha de Nac.:
Dirección: Tel.1:
Ocupación: Tel:2:
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1- Antecedentes Personales ------------------------------------------------------------------------------------

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2- Antecedentes -----------------------------------------------------------------------------------------------
Gineobstétricos

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3- Tabaco y otros
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4- Alergias
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5- Intolerancia a ------------------------------------------------------------------------------------------------
medicamentos
6- Intervenciones -----------------------------------------------------------------------------------------------
quirúrgicas

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7- Tratamientos
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anteriores
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8- Ejercicio y
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alimentación
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9- Funciones Vegetativas

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Enfermedad -----------------------------------------------------------------------------------------------
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1- Actual
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2- Antecedentes -----------------------------------------------------------------------------------------------

-3Comentarios
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Antecedentes -----------------------------------------------------------------------------------------------
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Hereditarios -----------------------------------------------------------------------------------------------
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1- Abuelos
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2- Padre
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3- Madre
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4- Hermanos -----------------------------------------------------------------------------------------------

Enfermedad -----------------------------------------------------------------------------------------------
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1- Actual
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2- Antecedentes -----------------------------------------------------------------------------------------------

-3Comentarios
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 Nombre:--------------------------------------------------------------

Fecha:------------- Peso:----------- Talla:------------ BMI:----------- R c/c:-----------

Frec. card.:--------- T/A B.D:--------- T/A Bl.:----------

Normal No fue hecho Anormal Comentarios

1-E. General _ _ _ -------------------------------

2- Piel/cabello _ _ _ -------------------------------

3Ojos _ _ _ -------------------------------

4- F. de Ojo _ _ _ -------------------------------

5- Oido,nariz,garganta _ _ _
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6- Dientes, encías _ _ _
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7-Cuello,tiroides _ _ _
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8- Mamas _ _ _
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9- Tórax _ _ _
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10- Corazón _ _ _
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11- Abdómen _ _ _
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12_Reg. inguinal _ _ _ -------------------------------

13- Aparato Locomotor

Columna _ _ _
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MMII/MMSS _ _ _
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Articulaciones _ _ _
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14- Pulsos periféricos _ _ _
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15- Estado neurológico _ _ _
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16- Estado mental _ _ _
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Comentarios--------------------------------------------------------------------------------------------------------------

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