Esqueleto de historia clinica

SERVICIO: ________________[pic 1]

GOBIERNO AUTONOMO MUNICIPAL DE COLCAPIRHUA

HOSPITAL MUNICIPAL ANDRES CUSCHERI

HISTORIA CLÍNICA:            N. HC: _______         HORA: ___ : ____          FECHA: ___ ___ ___/[pic 2][pic 3]

I-DATOS ESTADÍSTICOS        

Apellido Pat.: _______________ Apellido Mat.: ______________ Nombre: ____________________

Edad: _____  Fecha de nacimiento: ___ / ___ / _____  Ocupación: ___________  Sexo: F (  )  M (  )

Procedencia: _______________________ Residencia: ____________________________________

Religión: _____________ Teléfono: __________________ Persona responsable: _______________

II- FUENTE DE LA HISTORIA: ______________________________________________________________________

_______________________________________________________________________________________________________

III- MOTIVO DE CONSULTA: _______________________________________________________________________

_______________________________________________________________________________________________________

IV- ENFERMEDAD ACTUAL: ________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

V- ANTECEDENTES PERSONALES NO PATOLÓGICOS:

Alimentación: _______________________________________________________________________________________

Vivienda: ____________________________________________________________________________________________

Mascotas: ___________________________________________________________________________________________

Actividad física: _____________________________________________________________________________________

Vacunas: ____________________________________________________________________________________________

Alcohol: _____________________________________________________________________________________________

Tabaco: _____________________________________________________________________________________________

Drogas: _____________________________________________________________________________________________

VI- ANTECEDENTES PERSONALES PATOLÓGICOS:

Enf. niñez: ___________________________________________________________________________________________

Enf. Adulto: _________________________________________________________________________________________

Terapias Empleadas: (medicamentos) __________________________________________________________________

Hospitalización: _____________________________________________________________________________________

Accidentes y traumatismo: __________________________________________________________________________

Transfusión: _________________________________________________________________________________________

Alergias: _____________________________________________________________________________________________

VIII- ANTECEDENTES FAMILIARES:

Padre: _______________________________________________________________________________________________

Madre: ______________________________________________________________________________________________

Hermanos: __________________________________________________________________________________________

Hijos: ________________________________________________________________________________________________

Pareja: ______________________________________________________________________________________________

VII- ANTECEDENTES GINECOOBSTETRICOS:

G: ____  P: ____  A: ____  C: ____              FUM: ____ / ____ / ____            FPP: ____ / ____ / ____

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

Menarca: ____________________________________________________________________________________________

Ciclo menstrual: _____________________________________________________________________________________

...