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HISTORIA CLÍNICA

Nombres: ____________________________________________________Edad: ____________

Género: __________ Fecha y lugar de nacimiento: ___________________________________

Religión: __________________________ Nacionalidad: _______________________________

Procedencia: _____________________________ Teléfono: ____________________________

Domicilio: ____________________________________________________________________

Fuente de la historia: ________________________________________________________________________________

Motivo de consulta __________________________________________________________________________________

Enfermedad actual __________________________________________________________________________________


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Antecedentes personales

No patológicos

Vivienda___________________________________________________________________________________________

Alimentación_______________________________________________________________________________________

Hábitos y costumbres _______________________________________________________________________________

Sueño ____________________________________________________________________________________________

Mascotas __________________________________________________________________________________________

Antecedentes patológicos

Enfermedades niñez
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Enfermedades adulto
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Antecedentes traumáticos
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Hospitalizaciones
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Antecedentes quirúrgicos
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Hipersensibilidad
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Antecedentes inmunológicos
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Antecedentes familiares:
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Antecedentes ginecoostetricos

Menarca___________________________________________________________________________________________

Ciclo menstrual _____________________________________________________________________________________

Inicio vida sexual ____________________________________________________________________________________

Métodos de planificación familiar ______________________________________________________________________

FUM___________________________________________ FPP _____________________________________________

GESTAS____________PARTOS_______________CESARIAS_____________ABORTOS________

Menopausia _______________________________________________________________________________________

Revisión por sistemas

SNC
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SCP
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SGI
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SGU
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SME
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Examen físico general:

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Signos vitales

P/A: _____________ FC: ____________ FR: _____________ TO: ______________ PULSO: ____________

Piel y faneras
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Cabeza
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Oídos
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Nariz
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Ojos
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Boca
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Cuello
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Tórax
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Mamas
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Corazón
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Pulmones
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Abdomen
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Genitales
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Extremidades
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Examen neurológico
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Diagnostico

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Conducta

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