FORMATO DE HISTORIA CLINICA DE URGENCIAS

HISTORIA CLNICA DE URGENCIAS

1. Anamnesis
1.1 Identificacin
Documento De Identidad: ____________________________
Apellidos Y Nombres: _________________________________________________________
Edad:____________ Fecha Y Lugar De Nacimiento: _______________________________
Sexo : _____________ Estado Civil: ___________________________
Grupo Sanguneo: ________________
Direccin Actual:__________________________________
Telfonos:____________________ _______________________
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Responsable: _____________________________ Telfono: _________________________
Direccin:_________________________________ Ocupacin: _______________________
1.2 Motivo De Consulta:
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1.3 Historia De La Enfermedad Actual:
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1.4 Antecedentes Personales Y Familiares:
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2. Examen Fsico:
T __________ P.A ___________ F.R _______________ Pulso _____________
Observaciones:
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2.1. Revisin De Sistemas:
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3. Examen Extraoral:
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4. Examen Intraoral:
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5. Diagnostico Presuntivo:
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6. Exmenes Complementarios:
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7. Diagnostico:
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8.Pronostico:___________________________________________________________________
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9. Plan De Tratamiento:
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10. Evolucin:
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Firma Del Paciente O Persona Responsable:

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Firma del Odontlogo: _______________________________________
Firma del Estudiante: ________________________________________
Testigo: ___________________________________________________