UNIVERSIDAD MARIANA
FACULTAD CIENCIAS DE LA SALUD
PROGRAMA DE FISIOTERAPIA
FORMATO HISTORIA CLINICA
Fecha de ingreso: _______________ Fecha de evaluación: _______________
DATOS GENERALES
Nombres: __________________________________ Apellidos: ____________________________________
Tipo de identificación: CC____ TI____ CE_____ Número: ___________________
Género: F____ M____ Edad: _________ Lugar y fecha de nacimiento: ________
Estado civil: ____________________ Seguridad Social: ___________________
Nivel de escolaridad: _________________ lateralidad: ____________________
Ocupación: ______________________________________________________
Diagnostico CIE-10: ______________________________________________
Referenciado por especialidad: ____________________________________
Responsable: ____________________________________
Antecedentes:
Patológicos:
Quirúrgicos:
Psicológicos:
Hospitalarios
Toxicológicos
Traumatológicos:
Nutricionales:
Farmacológicos:
Familiares
Practica de actividad o ejercicio físico: ________________________________________________________________
________________________________________________________________________________________________
Exámenes complementarios: __________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Medicamentos actuales: ______________________________________________________________________________
__________________________________________________________________________________________________
Uso de equipos, dispositivos o ayudas externas: ___________________________________________________________
Condición que afecte la intervención: ___________________________________________________________________
__________________________________________________________________________________________________
Motivo de consulta: _________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Factores contextuales: _______________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Realizado por Comité de Autoevaluación y Gestión Curricular. Junio 2018
UNIVERSIDAD MARIANA
FACULTAD CIENCIAS DE LA SALUD
PROGRAMA DE FISIOTERAPIA
FORMATO HISTORIA CLINICA
EVOLUCIÓN HISTORIA CLÍNICA
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Realizado por Comité de Autoevaluación y Gestión Curricular. Junio 2018
