Esqueleto de historia clinica
Enviado por Maura Z • 26 de Agosto de 2019 • Síntesis • 321 Palabras (2 Páginas) • 724 Visitas
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: ______________________________________________________________________
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III- MOTIVO DE CONSULTA: _______________________________________________________________________
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IV- ENFERMEDAD ACTUAL: ________________________________________________________
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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: ____ / ____ / ____
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Menarca: ____________________________________________________________________________________________
Ciclo menstrual: _____________________________________________________________________________________
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