HISTORIA CLINICA
1. DATOS GENERALES
Nombre: ____________________________________________________________
Edad: _____ sexo: _______ No. Expediente: _________ Fecha: ______________
Estado civil: _________ Proc/residencia: ________________________________
Ocupación: ________________ Grupo étnico: __________________
2. MC:
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3. H. E Actual:
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RxS:
• S. Respiratorio: _____________________________________________
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• S. Cardiovascular: ___________________________________________
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• S. Nervioso psiquiátrico: ______________________________________
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• S. Gastrointestinal: ___________________________________________
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• S. Genitourinario: ____________________________________________
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• S. Osteomuscular: ___________________________________________
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• S. Endocrino: _______________________________________________
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• Piel y faneras: _______________________________________________
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• S. Linfático: ________________________________________________
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• S. Hematológico: ____________________________________________
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• S. ORL: ___________________________________________________
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• S. Ocular: __________________________________________________
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4. Antecedentes:
Personales patológicos:
• Familiares: __________________________________________________
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• Médicos: ___________________________________________________
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• Quirúrgicos: _________________________________________________
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• Traumáticos: ________________________________________________
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• Manías y vicios: _____________________________________________
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• Alérgicos: __________________________________________________
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• Ginecobstetricias: ____________________________________________
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Personales no patológico:
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Alimentación: __________________________________________________________
G: ____ P: ____ A: ____ HV: ____ C: ____ UR: _______
Menarquia: ______________ Papanicolau: ___________ Ciclo Menstrual: _________
Inmunización: __________________________________________________________
Estudios previos: ________________________________________________________
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Transfusiones: ________________ Grupo y Rh: ______________
EXAMEN FISICO:
Peso: ______ Talla: _______ Temperatura: ________ P/A: ____________ FC: _______
FR: ________ SPO2: _______ IMC: __________ Función Renal: _________________
Apariencia General: ______________________________________________________
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Piel y faneras: __________________________________________________________
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Ganglios: ______________________________________________________________
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Cabeza: ________________________________________________________________
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Ojos: _________________________________________________________________
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Oídos: ________________________________________________________________
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Nariz: _________________________________________________________________
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Boca: _________________________________________________________________
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Orofaringe: _____________________________________________________________
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Cuello: ________________________________________________________________
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Tórax: ________________________________________________________________
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Mamas: ________________________________________________________________
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Pulmones: _____________________________________________________________
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Corazón: ______________________________________________________________
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Abdomen: ______________________________________________________________
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Genitales internos y externos: _______________________________________________
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Tacto rectal: ____________________________________________________________
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Extremidades: __________________________________________________________
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Neurológico: __________________________________________________________
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Pares craneales: _________________________________________________________
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Reflejos osteotendinosos: ________________________________________________
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Sensibilidad: __________________________________________________________
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Equilibrio: ____________________________________________________________
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Reflejos patologicos: ____________________________________________________
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Observaciones: __________________________________________________________
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PERFIL SOCIAL:
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