Historia Clnica

Ficha de Identificacin.
Nombre: ________________________________________________________
Direccin: _______________________________________________________
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Sexo__________ Edad_____________ Telfono: ____________
Lugar y fecha de nacimiento: ________________________________________
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Ocupacin________________________ Estado civil: ____________________
Motivo de Consulta_________________________________________________

Antecedentes Personales (Sufre alguna enfermedad crnica degenerativa).

Especifique:__________________________________________________
____________________________________________________________
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Antecedentes y situacin actual.
1.- Padece alguna enfermedad?

SI

NO

Cual: ________________________________________________________
2.- Ha tenido alguna operacin?

SI

NO

Especifique: __________________________________________________

Historial ocular

(Ha usado lentes).

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Antecedentes mdicos familiares.

Padre: Vivo Si____
No____
Enfermedades que padece: _________________________________________
________________________________________________________________
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Madre: Viva S____
No____
Enfermedades que padece: __________________________________________

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Otros: ___________________________________________________________
________________________________________________________________
Enfermedades que padecen: _________________________________________
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Estado de salud activa.

BUENA / MALA
Especifique: _______________________________________________________

Toma algn medicamento?

SI

NO

Cul: _____________________________________________________________

Algn tipo de alergia?

SI

NO

Cul: _____________________________________________________________

Revisin de anexos.
_____________________________________________________________________________________
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Reflejos pupilares.
Consensual: __________________________________________________________________
_____________________________________________________________________________
Fotomotor: ____________________________________________________________________
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Acomodativo: _________________________________________________________________
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OBSERVACIONES:
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