Formato de Historia Clnica

Ficha de Identificacin.
Nombre: _______________________________________________________
Nombre del responsable:___________________________________________
Registro:______________ Fecha:______________________
Sexo__________ Edad___________
Ocupacin_______________________________________________________
Antecedentes Familiares:
Padre: Vivo Si____ No____
Enfermedades que padece:_________________________________________
_______________________________________________________________
_______________________________________________________________
Madre: Viva Si____
No____
Enfermedades que padece:_________________________________________
_______________________________________________________________
_______________________________________________________________
Hermanos: Cuntos? ______ Vivos _____
Enfermedades que padecen:________________________________________
_______________________________________________________________
_______________________________________________________________
______________________________________________________________
Otros:_________________________________________________________
_______________________________________________________________
Antecedentes Personales Patolgicos.(Detallar

los antecedentes de importancia clnica, as

como el tratamiento que recibe para cada situacin comrbida y su duracin)

Cardiovasculares:_________________________________________
Neumologicos:___________________________________________
Gastroenterologicos:______________________________________
Endocrinos:______________________________________________
Renales:________________________________________________
Reumaticos:_____________________________________________
Ex alcohlico, ex fumador, ex drogadicto:______________________
Medicamentos utilizados:___________________________________
_______________________________________________________________
_______________________________________________Otras
Especificaciones:_____________________________________
_______________________________________________________________
_______________________________________________

Antecedentes Personales No Patolgicos (se anotar aqu lo relacionado a

tabaquismo, uso de alcohol, as como diferentes adicciones y su duracin, de
igual forma se anotarn aqu, de requerirse, los antecedentes sexuales del
paciente.)
Alcohol:____________________________________________
Tabaquismo:_____________________________________________
Droga:____________________________________________
Inmunizaciones: _________________________________________
Otros.__________________________________________________________
_______________________________________________
_______________________________________________________________
_______________________________________________
Antecedentes Gineco-obsttricos:
Menarquia_________
Ritmo ____________
F.U.M.______________
G____
P_____
A______
C_______ I.V.S.A ______________
Uso de Mtodos Anticonceptivos:
Si ______
No _______
Cules?
_________________________________________________________
_______________________________________________________
Motivo de cesrea:________________________________________
_______________________________________________________
Padecimiento actual:
1.- Comienzo:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
2.- Evolucin:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
3.- Estado actual:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

Interrogatorio por aparatos y sistemas:

Aparato digestivo.
halitosis, boca
seca, masticacin, disfagia(odino),
pirosis, nausea, vomito,
(hematemesis),
dolor abd. meteorismo y flatulencias,
constipacin, diarrea, rectorragia,
melenas, pujo y tenesmo, Ictericia
coluria
y acolia, prurito cutneo,
hemorragias.

Aparato
cardiovascular.
Disnea, tos
(seca. prod.), hemoptisis, dolor
precordial, palpitaciones, cianosis
edema y manifestaciones perifericas
(acfenos, fosfenos, sncope,
lipotimia,
cefalea, etc)

Aparato respiratorio.
Tos, disnea,
dolor torcico, hemoptisis, cianosis,
vomica, alteraciones de la voz.

Aparato Urinario.
Alteraciones de la
miccin (poliuria, anuria,
polaquiuria,oliguria, nicturia,
opsiuria,
disuria, tenesmo vesical, urgencia,
chorro, enuresis, incontenincia)
caracteres de la orina (volumen,
olor,
color, aspecto) dolor lumbar, edema
renal, hipertensin arterial, datos
clnicos
de anemia.

Aparato genital.
Criptorquidia,
fimosis, funcin sexual. Sangrado
genital,
flujo o leucorrea, dolor ginecolgico,
prurito vulvar.

Aparato
hematolgico. Datos
clnicos de anemia (palidez, astenia,
adinamia y otros), hemorragias,
adenopatas, esplenomegalia.

Sistema endocrino.
Bocio, letargia
bradipsiquia (lalia), intol. calor/frio,
nerviosismo,
hiperquinesis, carac. sexuales,
galactorrea, amenorrea,
ginecomastia,
obesidad, ruborizacin.
Sistema osteomuscular. ganglios,
xeroftalmia, xerostomia,
fotosensibilidad
artralgias/mialgias, Raynaud.

Sistema nervioso.
cefalea, sncope,
convulsiones, deficit transitorio,
vertigo,
confusion y obnub., vigilia/sueo,
paralisis y M, marcha y equilibrio,
sensibilidad.

Sistema sensorial.
visin, agudeza,
borrosa diplopia, fosgenos, dolor
ocular,
fotofobia, xeroftalmia, amaurosis,
otalgia,
otorrea y otorragia, hipoacusia,
tinitus,
olfaccin, epistaxis, secrecin,
Geusis,
Garganta (dolor)
Fonacin.

Psicosomtico.
Personalidad,
ansiedad, depresin, afectividad,
emotividad, amnesia, voluntad,
pensamiento, atencin, ideacin
suicida,
delirios.

Exploracin fsica:
Signos Vitales. Peso: _____ Talla: _____ IMC: ______ TA: ______
FC: _____ FR: _____ Temperatura: _____
Habitus exterior:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Cabeza y Cuello:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Trax:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Abdomen:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Extremidades.
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Genitales:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Neurolgico y Estado Mental:
_______________________________________________________________
_______________________________________________________________
______________________________________
Laboratorio:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
______________________________________________________________

Estudios de Imagen.
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________
Otros___________________________________________________________
_______________________________________________________________
_______________________________________
_______________________________________________________________
_______________________________________________.
Comentarios:
_______________________________________________________________
_______________________________________________________________
_______________________________________
_______________________________________________________
IDx: ___________________________________________________
Tratamiento:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________

______________________________________
Medico responsable y firma
Cedula profesional: _____________
Ficha de identificacin:

Nombre: _______________________________________________________
Nombre del responsable:___________________________________________
Registro:______________ Fecha:______________________
Nota de evolucin:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
______________________________________________________________
Signos Vitales:
Peso: _____ Talla: _____ IMC: ______ TA: ______ FC: _____ FR: _____
Temperatura: _____
Laboratorios y Gabinete:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
DX: ____________________________________________________________
Tratamiento:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Indicaciones y comentarios:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

_______________________________________
Medico responsable y firma
Cedula profesional: _____________