HISTORIA CLÍNICA

I. DATOS PERSONALES

1. Nombre completo: ______________________________________________________

2. Tipo y # Documento de identificación : ____ _________________________
3. Edad: ______________
4. Sexo : _____________
5. Estado civil: ______________
6. Dirección: ________________________________________________________________________
7. Teléfono: ________________________________
8. Fecha de consulta: _____________________________

II. MOTIVO DE CONSULTA

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III. ENFERMEDAD ACTUAL

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IV. ANTECEDENTES PERSONALES

• Patológicos: ________________________________________________________________________________
• Quirúrgicos: _______________________________________________________________________________
• Alérgicos: __________________________________________________________________________________
• Transfusionales: ____________________________________________________________________________
• Ginecobstétricos:
FUM: ____________ G___P___C___A___ Anticonceptivos: ________________
Fecha de última citología: ___________________

V. ANTECEDENTES FAMILIARES
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VI. REVISION POR SISTEMAS

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VII. EXAMEN FISICO

• Signos vitales
TA: _____________ FC: _______ FR: ______ T°: ______ Peso: _______ Talla: ________
• Apariencia General: _________________________________________________________________________
• Cabeza: ___________________________________________________________________________________
• Cuello : ____________________________________________________________________________________
• Órganos De Los Sentidos: ____________________________________________________________________
• Cardiopulmonar: ___________________________________________________________________________
• Abdomen:__________________________________________________________________________________
• Genitourinario: _____________________________________________________________________________
• Extremidades: ______________________________________________________________________________
• Piel Y Faneras: _____________________________________________________________________________
• Sistema Nervioso: ___________________________________________________________________________

VIII. IMPRESIÓN DIAGNOSTICA

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XI. PLAN
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X. FIRMA DEL MEDICO TRATANTE

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R.M.
 EVOLUCIÓN
DATOS PERSONALES

1. Nombre completo: ______________________________________________________

2. Tipo y # Documento de identificación : ____ _________________________
3. Edad: ______________
4. Sexo : _____________
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