HISTORIA CLNICA

1. ANAMNESIS:

Fecha: ____________ Hora:_______ Cama: _______ Lugar de

consulta / Hospital:______________________________________________________

Identificacin:
Apellidos: ______________________________ Nombres: ______________________________
Tipo de identificacin: CC ___ / TI ___ / CE ___ N:___________________________________
Edad: ______ Sexo: F___ / M____ Orientacin sexual: ________________________
Grupo sanguneo: ____ RH: ____ Estado civil: __________ Nacionalidad:
_______________
Fecha de nacimiento: ____________ Lugar de nacimiento: ____________________________
Lugar de procedencia / Otros lugares donde ha vivido: __________________________________
Lugar de residencia: ______________ Direccin: ________________________ Estrato: _____
Telfono: ____________ Nivel de escolaridad: _______________ Religin:
________________

Ocupacin: __________________________ Etnia: ___________________________________

EPS: _______________________________ Tipo de afiliacin: __________________________

Nombre de contacto: ________________________________ Parentesco: _________________

Direccin: ________________________________________ Telfono: ___________________

Fuente de la historia:
Fuente de referencia:
Entrevistador:

Motivo de consulta o causa de ingreso:

_____________________________________________________________________________
_____________________________________________________________________________

Historia de la enfermedad actual:

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Aparicion Localizacin irradiacin concomitancia intensifica alivia.
Inicio spubito o progresivo. Predominio con alguna actividad u hora, ha pasado antes. Cuanto
duara el episodio y la intensidad 1 -10. Como ha evolucionado. Ha cambiado carcter, intesidad,
ha aparecido otro. Frecuencia de aparicin.
Antecedentes:
Personales:
- Patolgicos: ________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
- Quirrgicos: ________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

- Traumticos: ________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
- Farmacolgicos: _____________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
- Inmunizacin: _______________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

- Alrgicos: __________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

- Transfusionales: _____________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

- Sexuales: __________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

- Txicos:
Fuma: S___ No___, #cig/da__________.paq/ao_____________
Bebe: S___ No___, inicio______, frecuencia_________, cantidad__________________________
Narcticos: S___ No___, cantidad________, frecuencia________________________
Energizantes: S___ No___, cantidad________, frecuencia_______________________
Otros: S___ No___ Cal?________________________________________________________

Ginecoobsttricos: G __ P __ A __ C __ V __ M __ E __.
- FPR: ___________ FUR : _________ Ciclos Menstrual : __________.
- Inicio de la vida sexual: _______________. Inicio de vida obsttrica: _______________
- Menopausia :___________________________________________________
- Citologas:__________________________________________
- Mtodo de planificacin familiar: __________________________________
- ETS
Hospitalarios:___________________________________________________________________
_______________________________________________________________________
_________________________________________________________________________
Nutricionales:___________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

Actividad fisica: _________________________________________________________________

 __________________________________________________________________________
__________________________________________________________________________

Familiares: _____________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

Ocupacionales: _________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

Personal y social: ________________________________________________________________

__________________________________________________________________________
__________________________________________________________________________

Socioeconmicos: _______________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

REVISIN POR SISTEMAS:

Autopercepcin de la salud.
PSICOSOCIAL: INCONTINENCIA _____ CAIDAS _______ PROBLEMAS DE MEMORIA ______
Sntomas generales:
- Debilidad: _________________________________________
- Fatiga: _____________________________________________
- Cambios de peso: ___________________________________
- Fiebre: _____________________________________________
- Escalofros: _________________________________________
- Astenia: ____________________________________________
- Adinamia: __________________________________________
- Insomnio: ___________________________________________
- Hipersomnia: ________________________________________

Sistema neurolgico:
- Cefalea:
- Vrtigo:
- Sncope:
- Convulsiones:
- Temblores:

rganos de los sentidos:

Vison:
Agudeza visual: _____________________________________
Amaurosis: ________________________________________
Fotofobia: __________________________________________
Lagrimacin: _______________________________________
Epifora: ____________________________________________
Diplopas: __________________________________________
 Escotomas: _________________________________________
Fotopsias: __________________________________________
Flotadores en el vtreo: ________________________________
Dolor ocular (retro u orbicular): ________________________________________

Odo:
Otalgia: ____________________________________________
Otorrea: ___________________________________________
Otorragia: __________________________________________
Cofosis: ___________________________________________
Paracusia: _________________________________________
Acufenos: __________________________________________
Tinnitus: ___________________________________________

Nariz:
Obstruccin nasal: ___________________________________
Rinorrea: ___________________________________________
Rinoliquia__________________________________________
Anosmia: __________________________________________
Cacosmia: _________________________________________
Parosmia: __________________________________________
Epistaxis: __________________________________________

Boca:
Odontalgia: _________________________________________
Queilitis: ___________________________________________
Gingivitis: __________________________________________
Gingivorragia: _______________________________________
Glositis: ____________________________________________
Glosodinia: _________________________________________
Tialismo: ___________________________________________
Asialia: ____________________________________________
Odinofagia: _________________________________________
Disfagia: ___________________________________________
Xerostoma: ________________________________________
Halitosis: ___________________________________________
Agusia: ____________________________________________
Paragusia: _________________________________________

Cuello:
Dolor cervical: _______________________________________
Dolor msculo esqueltico: ____________________________
Masas: ____________________________________________

Torax:
Dolor torcico: ______________________________________
Mamas:
Mastodinia: _________________________________________
Telorrea: ___________________________________________
 Galactorrea: ________________________________________

Sistema cardiovascular:
Disnea: ____________________________________________
Palpitaciones: _______________________________________
Dolor precordial: _____________________________________
Cianosis: ___________________________________________

Sistema respiratorio:
Polipnea: __________________________________________
Taquipnea: _________________________________________
Bradipnea: _________________________________________
Batipnea: __________________________________________
Tos: ______________________________________________

Sistema gastrointestinal:
Acolia: _____________________________________________
Acoria: ____________________________________________
Agrieras: ___________________________________________
Anorexia: __________________________________________
Apetito: ____________________________________________
Bulimia: ____________________________________________
Constipacin: _______________________________________
Diarrea: ____________________________________________
Disfagia: ___________________________________________
Disgeusia: __________________________________________
Disquesia rectal: _____________________________________
Dolor abdominal: ____________________________________
Eructo: ____________________________________________
Esofagorragia: ______________________________________
Gastrorragia: _______________________________________
Hbito intestinal: _____________________________________
Hematemesis: ______________________________________
Hematoquesis: ______________________________________
Hemorragia digestiva: ________________________________
Hiperorexia: ________________________________________
Ictericia: ___________________________________________
Malacia: ___________________________________________
Melanemesis: ______________________________________
Melenas: ___________________________________________
Meteorismo: ________________________________________
Molestias ano rectales: ________________________________
Pujo: ______________________________________________
Tenesmo: __________________________________________
Encoprexis: _________________________________________
Nuseas: __________________________________________
Obstipacin: ________________________________________
Parorexia: __________________________________________
Pica: ______________________________________________
 Pirosis: ____________________________________________
Polifagia: ___________________________________________
Rectorragia: ________________________________________
Regurgitacin: ______________________________________
Sangre oculta: ______________________________________
Sitofobia: __________________________________________
Vmito: ____________________________________________

Sistema urinario:
Dolor: _______________________________
Alteraciones en el aspecto de la orina: __________________________________________
Trastornos en la eliminacin de la orina: __________________
Alteraciones del chorro de la orina: _____________________________________________

Aparato genital femenino:

Amenorrea: ________________________________________
Polimenorrea: ______________________________________
Oligomenorrea: _____________________________________
Menarquia: _____________________________________
Metrorragia: _____________________________________
Menorragia: _____________________________________
Menopausia: _____________________________________
Dismenorrea: _____________________________________
Leucorrea: _____________________________________
Prurito vaginal: _____________________________________

Aparato genital masculino:

Impotencia: _____________________________________
Priapismo: _____________________________________
Algopareunia: _____________________________________
Hemospermia: _____________________________________

Sistema osteomuscular y articular:

Dolor articular: _____________________________________
Rigidez articular: _____________________________________
Deformacin articular: _____________________________________

Sistema endocrino:
Alteraciones de la hipfisis: _____________________________________
Alteraciones de la tiroides: _____________________________________
Alteraciones de las adrenales: _____________________________________
Alteraciones de las gnadas: _____________________________________
Alteraciones del pncreas: _____________________________________

Sistema hematolgico y linftico:

Adenopatas: _____________________________________

Piel y anexos:
Prurito: _____________________________________
Otros: _______________________________________