HISTORIA CLINICA
Número de registro: _____________________ Fecha: _____/_____/______ Hora: __________
Nombre(s): _____________________________ Apellidos: ____________________________________
Cedula: _______________________________ Sexo: _________ Edad: ________ Seguro: __________
Lugar de nacimiento: ____________________________________ Etnia: _______________
Residencia/lugar ocasional: _____________________________________________________________
Ocupación: _______________________ Estado civil: ___________________ Hijos: __________
Grupo sanguíneo: _______ Religión: ___________________ Teléfono: _________________________
Nombre(s) del acompañante: __________________________________________________
Apellidos del acompañante: ____________________________________________________
Motivo de consulta
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Antecedentes Personales Patológicos
Cardiovasculares: _____ Pulmonares: _____ Digestivos: ______ Diabetes: _____ Renales: _____
Quirúrgicos: _____ Alérgicos: _____ Transfusiones: _____
Medicamentos________________________________________________________________________
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Especifique__________________________________________________________________________
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Paola de la Cruz Rodríguez | 2018-1162 UNIVERSIDAD CATOLICA DEL CIBAO
HISTORIA CLINICA
Antecedentes Personales No Patológicos
Alcohol: _________________________________________________
Tabaquismo: _____________________________________________
Drogas: _________________________________________________
Inmunizaciones: __________________________________________
Otros: _____________________________________________________________________________
Antecedentes Familiares:
Padre: Vivo: Sí ____ No ____
Enfermedades que padece:
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Madre: Viva: Sí ____ No ____
Enfermedades que padece:
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Hermanos: ¿Cuántos? ______ Vivos _____
Enfermedades que padecen:
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Otros: ___________________________________________________________
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Antecedentes Gineco-obstétricos
Menarquia: _________ Ritmo: ____________ F.U.M.______________
G: ____ P: _____ A: ______ C: _______
Paola de la Cruz Rodríguez | 2018-1162 UNIVERSIDAD CATOLICA DEL CIBAO
HISTORIA CLINICA
Uso de Métodos Anticonceptivos: Si ______ No _______
¿Cuáles? _________________________________________________________
¿Desde qué tiempo? _________________________________________________
Padecimiento actual
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Exploración física
Signos Vitales. T.A. (brazo derecho) _____ T.A. (brazo izquierdo) __________ F.C._______
[Link]. __________ Temp. ________Peso: _______ Talla: _______ IMC: _______
Piel:
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Cabeza:
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Ojos:
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Oídos:
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Paola de la Cruz Rodríguez | 2018-1162 UNIVERSIDAD CATOLICA DEL CIBAO
HISTORIA CLINICA
Nariz y senos paranasales:
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Boca, faringe y garganta:
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Cuello:
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Mamas:
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Tórax:
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Espalda:
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Sistema cardiovascular:
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Pulmones:
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Abdomen:
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Paola de la Cruz Rodríguez | 2018-1162 UNIVERSIDAD CATOLICA DEL CIBAO
HISTORIA CLINICA
Miembros superiores:
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Miembros inferiores:
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Neurológico y Estado Mental:
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Exploraciones adicionales
Tacto rectal:
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Exploración ginecológica:
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Laboratorio
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Estudios de Imagen
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Otros:
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Paola de la Cruz Rodríguez | 2018-1162 UNIVERSIDAD CATOLICA DEL CIBAO
