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HISTORIA CLINICA
FILIACION
| Nombre : |
| Edad : Sexo: |
|
Estado Civil: Ocupación: |
| Procedencia: Residencia: |
| Dir. No telf. |
| Nombre del servicio: |
| Sala: Cama: |
| Fecha y Hora de internaciòn: |
| Fecha y hora de Historia clinica: |
| Fuente de información: |
MOTIVO DE CONSULTA
HISTORIA DE LA ENFERMEDAD ACTUAL
| Inicio: |
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| Evolución: |
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| Estado Actual: |
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ANTECEDENTES PERSONALES NO PATOLOGICOS
| Procedencia: | Residencia: |
| Ocupación Actual: | Ocupación anterior: |
| Grado de escolaridad: | Lee …………. Escribe………… |
| VIVIENDA | |
| Luz ……….. Agua ……….. | Alcantarillado…………… |
| No de persona con las que vive: | No de habitaciones: |
| Hacinamiento……… | |
| ALIMENTACION: | |
| Calidad: | Cantidad: |
| Frecuencia: | Predominio: |
| Intolerancia: | |
| HABITOS SOCIALES: | |
| Consumo de alcohol: | Cantidad: |
| Frecuencia: | Predominio: |
| Consumo de tabaco: | Cantidad: |
| Desde que edad fuma: | Frecuencia: |
| Drogas: | Coca: |
| EMUNTORIOS: | |
| Catarsis: | Diuresis: |
| VACUNAS: | |
| | |
| SUEÑO: | Horas. |
| Deportes: | Frecuencia: |
| Religión: | |
ANTECEDENTES PERSONALES PATOLOGICOS
| Enfermedades de la infancia: |
| Enfermedades no quirúrgicas: |
| Enfermedades quirúrgicas: |
| Accidentes: |
| Traumatismos: |
| Fracturas: |
| Transfusiones de sangre: |
| Alergias: |
| Incapacidades: |
ANTECEDENTES FAMILIARES
| Abuela Materna: | Abuela paterna |
| Abuelo materno: | Abuelo Paterno |
| Padre: | Madre: |
| Hermanos: vivos: | Fallecidos: |
| Razòn de fallecimiento: | Edad: |
| Hijos: vivos: | Fallecidos: |
ANTECEDENTES GINECOOBSTETRICOS.
| Menarca: | FUM: |
| Gestas: Partos: | Abortos: |
| Fecha ultimo parto. | |
EXAMEN FISICO GENERAL
| Actitud: | Biotipo: |
| Facie: | Orientación: |
| Memoria: | Lenguaje: |
| IMC: | Piel y mucosas: |
| SIGNOS VITALES: | |
| PA: | Pulso: |
| Temperatura: | FR: |
| FC: | |
EXAMEN FISICO SEGMENTARIO
| Cabeza: |
| Cabello: |
| Frente: |
| Cejas: |
| Pàrpados: |
| Pestañas: |
| GLOBO OCULAR: |
| Escleròtica: |
| Iris: |
| Pupila: |
| NARIZ: |
| LABIOS: |
| OREJAS: |
| CUELLO: |
| Ganglios: |
| Tiroides: |
EXAMEN SEGMENTARIO RESPIRATORIO.
| Tipo de respiración: | Frecuencia: |
| Amplitud: | |
| INSPECCION: |
| |
| |
| PALPACION: |
| |
| |
Descargar
| Enviado por: | Kida |
| Idioma: | castellano |
| País: | Bolivia |