HISTORIA CLÍNICA
Fecha:
Hora:
Expediente:
1. IDENTIFICACIÓN DEL PACIENTE
Nombre: _________________________________________________________________
Apellido
paterno
Apellido Materno
Nombre (s)
Edad:
Sexo:
Edo. Civil:
Lugar de nacimiento: __________________ Fecha de
nacimiento:
Ocupación:
Dirección: ___________________________________________________________
Calle
Número
Colonia
C.P.
Ciudad
Estado
Teléfonos:
Responsable legal: ___________________________________________________
Fecha de
ingreso:
No. de cama: _____
Médico tratante: ______________________________________________________
Motivo de la consulta:
__________________________________________________________________________
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2. ANTESCEDENTES HEREDO-FAMILIARES
__
Diabetes
__ Hipertensión
arterial
__ Enfermedad
mental
__ Convulsiones
__
Cardiopatías
__ Atopia
_
Neoplasia
__ Enfermedades
tiroideas
__ Diatesis
hemorrágica
__ Alcoholismo
__
Consanguinidad
__ Urolitiasis
__
Obesidad
__ Anemias
__ Suicidio
__ Enfermedades
reumáticas
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Tuberculosis
__ Otros
Descripción de los positivos: ________________________________________________
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3. ANTESCEDENTES PERSONALES NO PATOLÓGICOS
Lugar de origen: ________________________________________________
Desarrollo locomotor (describir): _________________________________________
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Vacunas (describir): __________________________________________________
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Uso de: __ Tabaco __
Drogas __
Alcohol __ Fármacos
Descripción:__________________________________________________________________
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Alimentación habitual:
Si No
Desayuno
_ __
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Comida
_ __
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Cena
_ __
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Colaciones
_ __
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Servicios:
__ Agua
potable
_ Luz
eléctrica
_ Drenaje
_ Gas
No. de cuartos
_ __
Hacinamiento Baños
_______veces/semana
Limpieza dental _____ (veces/día)
Casa-habitación (material de construcción):_________________________________
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Deporte: __
Veces a la semana ______________
Ocupación:____________________________________________________________________
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Otros hábitos:
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4. ANTESCEDENTES PERSONALES PATOLÓGICOS
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Amigdalitis
__ Enfermedades venéreas __
Transfusiones
__
Parasitosis
__
Alcoholismo
__
Infarto miocardio
__
Paludismo
__
Traumatismos
__
Cirugías
__
Neoplasias
__
Farmacodependencia
__ Hepatitis
__
Alérgicos
__ Fiebre
reumática
__
Otros
Descripción:__________________________________________________________
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5. ANTESCEDENTES GINECO-OBSTÉTRICOS
Menarca _____ años
Menstruación:
Ritmo ______ Cantidad
__________ Apósitos/día
______ Dolor
____
Descripción:__________________________________________________________________
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FMV ______________ VSA
Gestas _______
Paras_______ A
_______ C_______
FUP_______
Anticoncepción: Si
No
Descripción:__________________________________________________________________
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Menopausia: ________________________________________________________
Anormalidades menstruales y otras:
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6. PADECIMIENTO ACTUAL
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7. INTERROGATORIO POR APARATOS Y SISTEMAS
Digestivo:________________________________________________________________
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Respiratorio: __________________________________________________________
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Cardiovascular: ___________________________________________________________
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Genitourinario: ____________________________________________________________
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Endócrino: _______________________________________________________________
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Hemático:
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Linfático: _________________________________________________________________
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Musculoesquelético: ____________________________________________________
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Tegumentario:____________________________________________________________
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Nervioso: _________________________________________________________________
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8. SÍNTOMAS GENERALES
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9. EXÁMENES DE LABORATORIO Y GABINETE
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10. DIAGNÓSTICOS PREVIOS
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11. TERAPEÚTICA EMPLEADA
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12. EXPLORACIÓN FÍSICA
FC. _________ FR.
__________ TA. ________
_ Temperatura
__________
Talla. __________ Peso. __________
Hábitus exterior:
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- Cabeza: ______________________________________________________________
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- Cuello:_____________________________________________________________
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- Tórax: _________________________________________________________________
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______________________________________________________________- Abdomen:
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- Genitales:
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- Extremidades:
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- Columna vertebral:
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- Piel y anexos: ________________________________________________________
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13. DIAGNÓSTICOS DEFINITIVOS
· _______________________________________________________________________
· _______________________________________________________________________
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DATOS DEL EXPLORADOR
Nombre: ___________________________________________
Categoría: _______________________________
Lugar: ___________________________________
Fecha: ___________________________________