1

UNIVERSIDAD AUTNOMA DE GUADALAJARA

PROGRAMA DE MEDICINA EN LA COMUNIDAD
FORMATO PARA HISTORIA CLNICA BSICA
2011/01
Basado en la NOM-SSA 1998 (2003)
Nmero Expediente___________Fecha (dd, mm, aaaa)_____________Hora_______
Tipo de Interrogatorio: Directo____ Indirecto______
I. IDENTIFICACIN DEL PACIENTE:
Nombre:______________________________________Edad________Sexo________
Ocupacin__________________ Edo. Civil_____________Religin_______________
Domicilio___________________________________Col._______________________
Cd.___________________________________Edo._____________Pas___________
Escolaridad__________________Lugar de Nacimiento_________________________
Lugar de residencia______________________
Telfono_________________Correo electrnico______________________________
Referencia:______________________Grupo sanguneo y Rh____________________
Alergias______________________________________________________________
Acompaante o responsable______________________________Telfono o domicilio de
ste_______________________________________________________________
II. ANTECEDENTES HEREDOFAMILIARES:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
________________
III. ANTECEDENTES PERSONALES PATOLGICOS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________________________
IV. ANTECEDENTES PERSONALES NO PATOLGICOS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________________________
V. MOTIVO DE CONSULTA:
______________________________________________________________________________
________________________________________________
VI. DESCRIPCIN DEL ESTADO GENERAL DE SALUD Y PADECIMIENTO(S) ACTUAL(ES):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________
VII. INTERROGATORIO SOBRE RGANOS, APARATOS Y SISTEMAS:
1. rganos de los sentidos:
1.1. Visin:__________________________________________________________
1.2. Audicin:________________________________________________________
1.3. Olfacin:________________________________________________________
1.4. Gusto:__________________________________________________________
1.5. Tacto:__________________________________________________________
2. rgano de la piel:
2.1. Piel: _____________________________________________________________
2.2. Uas_____________________________________________________________
2.3. Pelo:_____________________________________________________________
3. Aparato Respiratorio:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
__________________
4. Sistema Cardiovascular:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
__________________
5. Aparato Gastrointestinal:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
__________________
6. Aparato Genitourinario:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
__________________
7. Sistema Nervioso:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
__________________

8. Sistema Msculo-esqueltico:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
__________________
VIII. EXPLORACIN FSICA:
1. Habitus exterior:
______________________________________________________________________________
______________________________________________________________________________
__________________________________________
2. Somatometra y signos vitales:
TA_____________FC:_________FR:_____Temp_____Peso_____Talla____
IMC_____Permetro Abdominal_________
3. Cabeza:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________
4.
Ojos:_________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________
5.
Odos:________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________
6.
Nariz:_________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________
7.
Boca:_________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________
8.
Cuello:________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________
9. Trax posterior:____________________________________________________
______________________________________________________________________________
______________________________________________________________________________
__________________________________________
10. Trax anterior:_____________________________________________________
______________________________________________________________________________

______________________________________________________________________________
__________________________________________
11.
Abdomen:_____________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________
12. Extremidades superiores:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________
13. Extremidades inferiores:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________
14. Columna vertebral:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________
15. Examen Plvico:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________
IX. EXMENES O ESTUDIOS PREVIOS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________
Nombre y firma del alumno _________________________Registro_______________
Semestre______ Nombre del mdico responsable_____________________________
Firma____________________________. D.G.P______________________________
Fecha de entrega: __________________ Sello de la Unidad:
Yo__________________________________ hago constar que todo lo aqu escrito es
verdad y despus de haber ledo a conciencia, estampo mi firma de conformidad:

REPORTE FINAL DE PRCTICAS CLNICAS

Con la finalidad de obtener una adecuada retroalimentacin sobre el perodo de prcticas clnicas
realizadas, le solicitamos que llene el siguiente reporte con la mayor veracidad posible. Los datos

reportados son para uso exclusivo del departamento acadmico del Programa de Medicina en la
Comunidad, y son estrictamente CONFIDENCIALES. Agradecemos su participacin.
Favor de llenar los espacios en blanco y marcar con una cruz la respuesta que ms se acerque a su
realidad.

Fecha de Prcticas Clnicas________al__________de_____________del (ao)__________

Unidad Mdica (Nombre)_____________________________________________________
Profesor encargado_________________________________________________________
A. Desempeo del Profesor
Para
calificar las
acciones de
este
Apartado, se
evaluar en
la escala de
5= Siempre,
4= Casi
siempre,
3=Algunas
veces, 2=
Casi nunca,
1= Nunca.
Actividad

1. Demostr habilidades clnicas en la consulta

2. Realiz prctica entre iguales

3. bserv la ejecucin de habilidades clnicas del alumno ante el paciente

4. Proporcion asesora y retroalimentacin sobre el desempeo en la prctica con paciente