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HISTÓRIA CLÍNICA
DATOS PERSONALES
Nombre: 			Edad: 	 Fecha de Nacimiento: 			Sexo Raza: 			 Estado Civil: 		Ocupación: Religión: Nacionalidad: 			 Dirección: 
EN CASO DE EMERGENCIA LLAMAR A:			Teléfono: _______________
FECHA: ____/____/______		HORA: 
MOTIVO DE CONSULTA: ________________________________________________________
Datos aportados por el paciente y familiar: ____________________________.
A.E.A. (ANTECEDENTES DE LA ENFERMEDAD ACTUAL):
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A.R.E.A – 
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APP (ANTECEDENTES PATOLÓGICOS PERSONALES):
Enfermedades de la infancia: ________________________________________________________
 _________________________________________________________________________________
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APNP (ANTECEDENTES PERSONALES NO PATOLÓGICOS)
ANTECEDENTES FISIOLÓGICOS:
Antecedentes Inmunológicos: _______________________________________________________
Antecedentes Ginecológicos Y Obstétricos: Menarca: _______________ FUM: ____________ 
Edad de la menopausia: __________ Nº de partos: ___ Nº de hijos vivos: ______ Abortos: __
ANTECEDENTES DE MEDIO (SOCIOECONOMICO):
Vivienda: ___________________________________________________________________	
Servicios Sanitarios: _______________________________________________________________
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Servicios Básicos: _________________________________________________________________
Nº de hijos: _______________________________________________________________________
Escolaridad: ______________________________________________________________________
ANTECEDENTES DE HÁBITOS FISIOLÓGICOS
Hábitos Alimentares: ______________________________________________________________
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Ingesta De Agua: __________________________________________________________________ 
Catarsis Intestinal: ________________________________________________________________
Diuresis: _________________________________________________________________________
Sueño: __________________________________________________________________________
Actividad Física: __________________________________________________________________
ANTECEDENTES DE HÁBITOS VICIOSOS:
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ANTECEDENTES HEREDITÁRIOS Y FAMILIARES:
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EXAMEN FISICO GENERAL:
ECTOSCOPIA: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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SIGNOS VITALES: 
Temperatura Axilar ______________________FR ___________FC ________________________
Pulso Radial: ____________________________Pa ______________________________________
Peso Habitual: _______________ Peso actual: _______________* Talla: 1,45 mt IMC: _______
EXAMEN FÍSICO REGIONAL:
CABEZA: Cráneo y Cara
Cráneo: __________________________________________________________________________
Cabello: _________________________________________________________________________
Orejas: Pabellón auricular: __________________________. Conducto auditivo externo __________
Ojos: ________________; Pupilas: __________________. Esclerótica: ______________________
Córnea: ______________________________ Conjuntiva: _______________________________
Nariz: ___________________________________________________________________________
Boca: ____________________________________________________________________________
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Cuello: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
TORAX 
Inspección:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Palpación:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Percusión:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Auscultación:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
APARATO CARDIOVASCULAR:
ÁREA CENTRAL 
Inspección general:
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Inspección y Palpación: 
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Percusión: 
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Auscultación: 
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ÁREA PERIFÉRICA: 
Arterial:
Pulsos:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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Tensión Arterial: 
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Venoso: 
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ABDOMEN
Inspección: 
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Auscultación: _________________________________________________________________________________
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Palpación: 
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Percusión:
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Hígado: _________________________________________________________________________________
Bazo: _________________________________________________________________________________
Riñón: _________________________________________________________________________________Genitourinario: __________________________________________________________________________________________________________________________________________________________________
SISTEMA OSTEO ARTRO MUSCULAR: 
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SISTEMA NERVIOSO: 
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________PARES CRANEALES 
l Nervio olfatório – _______________________________________________________________
ll Nervio Optico – ________________________________________________________________
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lll,lV,Vl Oculomotor común , patético , Abducens – _____________________________________
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V – Trigemino: ___________________________________________________________________
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Vll – Facial – _____________________________________________________________________
Vlll Vestibulo coclear – _____________________________________________________________
IX – Glosofaringeo – _______________________________________________________________
X- Neumogastrico – ________________________________________________________________
Xl Nervio Espinal – – ______________________________________________________________
Xll Nervio Hipogloso – – ____________________________________________________________
RESUMEN SEMIOLÓGICO:
Datos Personales: _________________________________________________________________
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Motivo de Consulta: _______________________________________________________________
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ANTECEDENTES 
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ENFERMEDAD ACTUAL
Datos positivos: 
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Datos Negativos:
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_________________________________________________________________________________CONSIDERACIONES DIAGNÓSTICAS:
Diagnósticos presuntivos: 
Diagnósticos Sindrómicos:
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Diagnósticos Diferenciales:
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EXAMES COMPLEMENTÁRIOS: __________________________________________________
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