GUIA DE HISTORIA CLINICA

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HISTORIA CLINICA
INTERROGATORIO: 
DATOS DE FILIACION 
Nombres y apellidos:__________________________________________________________________
Sexo:____________ Edad:___________ Estado civil: ________________
Nacionalidad:______________________________________
Domicilio actual:___________________________________
Ocupación actual/Profesión:___________________________
Religión:________________________
Fecha y hora de ingreso:_____________________________
Los datos fueron aportados por _____________________________y merecen fe/relativa fe/no merecen fe.
MOTIVO DE CONSULTA: _______________________________________________________________________________________
ANTECEDENTES DE LA ENFERMEDAD ACTUAL (AEA): _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
ANTECEDENTES REMOTOS DE LA ENFERMEDAD ACTUAL (AREA): En caso de no presentar, poner: El paciente no refiere episodio similar.
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ANTECEDENTES PATOLÓGICOS PERSONALES (APP): En caso de no referir, poner: El paciente niega haber padecido de
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ANTECEDENTES PATOLÓGICOS FAMILIARES (APF): Preguntar sobre padre/madre/Hermanos/hijos. 
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HÁBITOS: 
Fisiológicos: Alimentos/ diuresis/ catarses/ actividad física.
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Tóxicos: Alcooh/tabaco/drogas 
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EXAMEN FÍSICO
SIGNOS VITALES: 
PA:_______mmHg Pulso:______lt/min FR:______resp/min T. Axilar:____ °Celsius. StO2:_______
Abdomen: 
Inspeción:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Auscultación:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Palpación:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Percusión:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________