23 de enero

FICHA
CLINICA

2013
SEMIOLOGIA

Datos Generales
Nombre: ________________________________________________________________________
Gnero: __________________Edad: __________________Etnia: ___________________________
Religin: _________________________________________________________________________
Estado Civil: ______________________________________________________________________
Domicilio: ________________________________________________________________________
Lugar de procedencia: ______________________________________________________________
Ocupacin: ______________________________________________________________________
Motivo de Consulta
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Historia de la Enfermedad Actual
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Revisin por sistemas
SISTEMAS
SI
NO
Cabeza
Ojos
Odos
Nariz
Boca y garganta
Cuello
Mamas
Cardaco
Respiratorio
Gastrointestinal
Urinario
Genital
Msculo- esqueltico
Endocrino
Piel y mucosa

Sntomas de Carcter General

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Antecedentes
Antecedentes Personales:
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Paciente Femenino
Ginecolgico
Gestos:
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Partos:
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Cesreas:
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ltima Regla: _____________________________________________________________________
Menarqua: ______________________________________________________________________
Presenta una enfermedad ya diagnosticada:
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Fecha para trabajo de parto: ________________________________________________________
Usa anticonceptivos: _______________________________________________________________

Antecedentes personales Fisiolgicos (No patolgicos):

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Antecedentes Personales Patolgicos

Mdicos:
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Quirrgicos:
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Traumticos:
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Alrgicos:
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Toxicomana:
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Antecedentes Familiares:
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Antecedentes Hereditarios:
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Perfil Social:
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Paciente menor de 6 aos (Ficha clnica peditrica)

Peso: ________Talla: ______________ Circunferencia enceflica: ___________________________
Nombre de la madre: ______________________________________________________________
Nombre del padre: ________________________________________________________________
Plan teraputico
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Plan educacional

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