Ficha clnica

Datos personales
Nombre paciente:____________________________________________ N ficha:____________
Domicilio:____________________________________ Edad:_________ Sexo:_______________
Profesin: ____________________________ Previsin: __________________
Diagnostico de ingreso: ___________________________________________________________
Derivacin: __________________________
Enfermedades de base:___________________________________________________________
PA: ______________ FC:________(lpm)
FR: _______ Diabetes:_____ Fumador:______
Peso:_______
Altura:_______
Medicamentos:________________________________________________________________________
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Anamnesis remota (enfer. Previas)

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Anamnesis prxima (motivo actual de consulta)
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Exmenes complementarios
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Evaluacin quinsica
I.
Inspeccin
a. Dinmica (marcha)
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b. Esttica (postura)
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c. Estado general del paciente
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d. Segmentaria
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II.

Palpacin
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III.

Auscultacin
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Tratamiento quinsica
Objetivos de tratamiento
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Sesin

Detalle tratamiento

Firma paciente

Firma profesional