DOCTORS UBBJ OFFICE

CLINIC HISTORY

PREPARATION DATE______________________ TIME_____________

NO FILES:
IDENTIFICATION FILE

NAME OF PATIENT:

AGE: SEX: OCCUPATION: MARITAL STATUS:

DATE OF BIRTH: LOCATION OF BIRTH:

SCHOOLING: ADDRESS:

INTERROGATION

1.HERITABLE FAMILY BACKGROUND:

DIABETES: HYPERTENSION: EPILEPSY: AIDS:

CARDIOVASCULAR: LUETICS: FIMICOS: NEOPLASMS:

2. NON-PATHOLOGICAL PERSONAL HISTORY:

FEEDING:

HYGIENE:

IMMUNIZATIONS:

3. PERSONAL PATHOLOGICAL HISTORY:

SURGICAL: TRAUMATIC:

TRANSFUSIONAL: ALLERGIC:

CHRONICODEGENERATIVES:

TYPE OF EVOLUTION: TREATMENT:

ALCOHOLISM: YES NO AGE OF ONSET: TYPE OF DRINK:

SMOKING: YES NO AGE OF STARTING: CIGARS PER DAY:

TOXICOMANIAS: YES NO AGE OF ONSET: SPECIFY:

FORMER ALCOHOLIC: YES NO FORMER ADDICT: YES NO TIME:

4.OBSTETRIC GYNECOLOGY HISTORY:

MENAARCH: CYCLES: IVSA: NO. SEXUAL COUPLES:

MPF: PREGNANCY: DELIVERY: CAESAREAN SECTIONS:

ABORTIONS: LIVE BORN: COMPLICATIONS:

FUM: LAST DATE OF PAPAMICOLAOU:

LAST MASTOGRAPHY DATE:

5.CURRENT CONDITION:

6. INTERROGATION BY DEVICES AND SYSTEMS:

RESPIRATORY:

CARDIOVASCULAR:

DIGESTIVE:

GENITOURINARY:

MUSCLE- SKELETAL:

HIGHLY STRUNG:

TEGUMENTARY:

PHYSICAL EXPLORATION

1.SOMATOMETRY AND VITAL SIGNS

BP: mmHg WEIGHT: kg SIZE: m BMI: m²/kg

HR: x RR: x TEMPERATURE: °c SAT: O2:

2. OUTDOOR HABITUS:

3. HEAD EXAMINATION:

4.NECK EXPLORATION:

5. CHEST EXAMINATION:

6.ABDOMINAL EXPLORATION:

7. MUSCLE AND VASCULAR EXPLORATION:

8. NEUROLOGICAL EXPLORATION:

COMPLEMENTARY STUDIES:

DIAGNOSIS :

TREATMENT :

NAME AND SIGNATURE OF PATIENT

NAME, SIGNATURE AND IDENTIFICATION OF THE DOCTOR

ADDRESS OF CONSULTATION :
 DOCTORS UBBJ OFFICE

Morelos 3721, central colony, Tehuacán puebla

FRONT SHEET OF THE CLINICAL RECORD

NAME OF PATIENT

FILE NUMBER

AGE SEX

DATE OF ATTENTION

DIAGNOSIS

HOME