hoja 1

YUMBREL S.R.L. FECHA:………/………./201…….-

HISTORIA CLINICA

Nombre y Apellido:………………………………………………...………………………………………………………………….
D.N.I. Nº……………………………………F.N.:……………………………..O.S.y Nº:………………...…………………………….
Domicilio:……………………….…….…...…………….Lugar de Nacimiento:……………………………………………….
Residencias anterior:………………………………………………………………………………………………………………………
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Familiograma

Historia de Vida:……………………………………………………………………………………………………………………………..
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 hoja 2
YUMBREL S.R.L.
HISTORIA CLINICA

Antecedentes:
Familiares: Padre/Madre:………………………………………………………………………………………………………………………….
Abuelos/tios:…………………………………………………………………………………………………………………….
Hermanos:………………………………………………………………………………………………………………………………..

Personaless:
Perinatales: EG: ………………………………..Peso al nacer:………………………….Apgar:……………………………………
Patologias perinatales:………………………………………………………………………………………………………………………………….
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Enfermedades cronicas:………………………………………………………………………………………………………………………………..
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Otros diagnosticos:…………………………………………………………………………………………………………………………..
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Tratamiento Farmacologico que recibe:………………………………………………………………………………………………………
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Vacunas:………………………………………………………………………………………………………………………………………………….
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Dieta:……………………………………………………………………………………………………………………………………………………………..
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Asistencia a otras instituciones socio-culturales:………………………………………………………………………………………..
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hoja 3
YUMBREL S.R.L.
HISTORIA CLINICA

Grado de independencia: ……………………………….………… ……………………………………,,,,,,…………………………………………

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Profesionales Especialistas que intervienen en su atención¨:

Especialidad Nombre Motivo
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hoja 4
YUMBREL S.R.L.
HISTORIA CLINICA

Lista de Problemas
Problema Fecha deteccion Profesional Fecha Solucion
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hoja 5
YUMBREL S.R.L.
HISTORIA CLINICA

Pruyecto Terapeutico
Salud:

Educacion:
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 hoja 2
YUMBREL S.R.L.
HISTORIA CLINICA

Antecedentes:
Familiares: Padre/Madre:………………………………………………………………………………………………………………………….
Abuelos/tios:…………………………………………………………………………………………………………………….
Hermanos:………………………………………………………………………………………………………………………………..

Personaless:
Perinatales: EG: ………………………………..Peso al nacer:………………………….Apgar:……………………………………
Patologias perinatales:………………………………………………………………………………………………………………………………….
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Enfermedades cronicas:………………………………………………………………………………………………………………………………..
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Otros diagnosticos:………………………………………………………………………………………………………………………………………..
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Tratamiento Farmacologico que recibe:………………………………………………………………………………………………………
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Vacunas:………………………………………………………………………………………………………………………………………………………….
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Dieta:……………………………………………………………………………………………………………………………………………………………..
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Asistencia a otras instituciones socio-culturales:………………………………………………………………………………………..
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 hoja 3
YUMBREL S.R.L.
HISTORIA CLINICA

Grado de independencia: ……………………………….……… ……………………………………,,,,,………………………………………

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……………………………………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………………………………….

Profesionales Especialistas que intervienen en su atención¨:

Especialidad Nombre Motivo
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 hoja 2
YUMBREL S.R.L.
HISTORIA CLINICA

Lista de Problemas
Problema Fecha deteccion Profesional Fecha Solucion
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 hoja 2
YUMBREL S.R.L.
HISTORIA CLINICA

Pruyecto Terapeutico
Salud:

Educacion: