HISTORIA CLINICA “HOGAR DE ANCIANOS SAN JOSE”
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1) DATOS ESTADISTICOS
Nombre y Apellidos: ______________________________________________________________________________Edad: __________
Sexo:________Procedencia:_________________Teléfono:___________________Ocupación:____________________________________
Estado Civil: _________________ Dirección: ____________________________Grado de Instrucción:
_____________________________ Fecha de elaboración: ______/______/_______
2) FUENTE DE LA HISTORIA – persona que dá los dactos
a) Propio (a) paciente merece confianza
b) Propio (a) paciente NO merece confianza
c) Parientes, amigos, vecinos, otros los cuales merecen confianza
d) Parientes, amigos, vecinos, otros los cuales NO merecen confianza
3) MOTIVO DE CONSULTA
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4) ENFERMEDAD ACTUAL
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5) ANTECEDENTES PERSONALES
a) No Patológicos
Vivienda:____________________________________________________________________________________________
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Alimentación:________________________________________________________________________________________
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Hábitos y Costumbres:
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b) Patológicos
Enfermedades de la Niñez: _____________________________________________________________________________
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Enfermedades de Adulto: ______________________________________________________________________________
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Hospitalizaciones: ____________________________________________________________________________________
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Antecedentes Traumáticos: ____________________________________________________________________________
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Antecedentes Quirúrgicos: _____________________________________________________________________________
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Alergias: ___________________________________________________________________________________________
6) ANTECEDENTES HEREDO FAMILIARES
Padre: __________________________________________________________________________________________________
Madre: __________________________________________________________________________________________________
Hijos: ___________________________________________________________________________________________________
Esposo(a): _______________________________________________________________________________________________
7) ANTECEDENTES GINECOOBSTETRICOS
Menarca: ___________________________Ciclo Menstrual: _____________________________________________________
Inicio de Vida Sexual Activa: _________________________
Métodos de Planificación Familiar: ___________________________________________________________________________
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Fecha de Ultima Menstruación: __________________________ Fecha Probables de Parto: ______________________________
Gestas: _________ Partos: __________ Abortos: _________ Cesáreas: ___________
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Menopausia: _______________________________________________________________________
8) REVISION POR SISTEMAS
SNC: ____________________________________________________________________________________________________
SCP: ____________________________________________________________________________________________________
SGI: ____________________________________________________________________________________________________
SGU: ___________________________________________________________________________________________________
SME: ___________________________________________________________________________________________________
9) EXAMEN FISICO GENERAL
Paciente se encuentra en: __________________________________________________________________________________________
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SIGNOS VITALES:
PA: ______/______ FC: __________ FR: __________ Pulso: __________ T: _________ IMC: _________ SPO2: ____________
10) EXAMEN FISICO REGIONAL
Cabeza: _________________________________________________________________________________________________
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Ojos: ___________________________________________________________________________________________________
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Nariz: ___________________________________________________________________________________________________
Oídos: __________________________________________________________________________________________________
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Orofaringe: ______________________________________________________________________________________________
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Cuello: __________________________________________________________________________________________________
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Tórax: __________________________________________________________________________________________________
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Mamas: _______________________________________________________________________________________________
Corazón: ________________________________________________________________________________________________
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Pulmón: ________________________________________________________________________________________________
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Abdomen: _______________________________________________________________________________________________
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Genitales: _______________________________________________________________________________________________
Extremidades: ____________________________________________________________________________________________
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11) IMPRESIÓN DIAGNOSTICA:
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12) CONDUCTA:
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Responsable de la Historia Clínica
