FECHA __________

I. ANANMESIS

Directa ( )

Indirecta ( )

1.1. FILIACIN
Apellidos y Nombres: ________________________________________________________________________________________
Edad: __________ Sexo: _________Raza: _______________________Color de Piel: ______________________________________
F. de Nacimiento: ___________________ Lugar de Nac.: ________________________Idioma: ______________________________
Nacionalidad: ________________ Procedencia: _____________ Estado Civil: ____________________________________________
Profesin u Ocupacin: ________________________ Donde Trabaja: __________________________________________________
Direccin: __________________________________________________________________________________________________
Telfono / Celular: ___________________________________________________________________________________________

1.2 ENFERMEDAFD ACTUAL

Motivo de consulta (Sntoma principal) ___________________________________________________________________________
___________________________________________________________________________________________________________
Tiempo de la Enfermedad: _____________________________________________________________________________________
Curso de la enfermedad: _______________________________________________________________________________________
Signos y sntomas principales: ___________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Relato de la Enfermedad: ______________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Funciones Biolgicas (apetito, sed, sueo, Diuresis, sudoracin, Deposiciones): ___________________________________________
___________________________________________________________________________________________________________
1.3 ANTECEDESTES PERSONALES
Generales: (inmunizaciones, hbitos, vivienda, alimentacin, higiene, condicin socioeconmica)_____________________________
Fisiolgicos: (menstruacin, gestacin)____________________________________________________________________________
Patolgicos: _________________________________________________________________________________________________
Familiares: __________________________________________________________________________________________________
Odontolgicos: ______________________________________________________________________________________________
___________________________________________________________________________________________________________
II. EXAMEN CLNICO
2.1 EXAMEN CLNICO GENERAL: (impresin general, estado de hidratacin, nutricin, emocional; LOTEP, peso, talla, grado de colaboracin
,tipo constitucional)_____________________________________________________________________________________________
_________________________________________________________________________________________________________________
2.2SIGNOS VITALES:(PA,FR,T,Pulso)________________________________________________________________________________
2.3 EXAMEN CLNICO REGIONAL:
Extraoral (piel y anexos, forma de crneo y cara, perfil anteroposterior, simetra facial, tono muscular, ATM, labios, fonacin,
respiracin, visin, audicin, sistema linftico, deglucin)_____________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Intraoral: (apertura bucal, frenillos, carrillos, fondo de surco, paladar, piso de boca, lengua, orofaringe, glndulas y conductos
salivales, encas, higiene oral)
__________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________

N DE
DIENTE

1.8 1.7

1.6 1.5 1.4

1.3

1.2 1.1

2.1 2.2

5.2

6.1

5.1

8.5

6.4

8.4

4.6

7.4

4.3

Estado de Salud periodontal

6.5
7.5

8.1 7.1 7.2

4.2 4.1 3.1 3.2

4.5 4.4

3.4 3.5

3.6

3.7

3.3
DI-S y CI-S
ndice de HO-S

Oclusin(Segn Angle)

2.8

7.3
8.2

4.7

2.7

6.3

5.4

8.3

4.8

2.4 2.5 2.6

6.2

5.3
5.5

DESCRIPCIN

2.3

3.8

1.8
1.7
1.6
1.5/5.5
1.4/5.4
1.3/5.3
1.2/5.2
1.1/5.1
2.1/6.1
2.2/6.2
2.3/6.3
2.4/6.4
2.5/6.5
2.6
2.7
2.8
3.8
3.7
3.6
3.5/7.5
3.4/7.4
3.3/7.3
3.2/7.2
3.1/7.1
4.1/8.1
4.2/8.2
4.3/8.3
4.4/8.4
4.5/8.5
4.6
4.7
4.8
OBSERVACIONES:

CPO-D

Registro de Prtesis
Exmenes Complementarios

TRATAMIENTOS A REALIZAR

FECHA

PRESUPUESTO

TRATAMIENTO

ADELANTO

FECHA

CITA

FECHA _____________
I. ANANMESIS

Directa ( )

Indirecta ( )

1.1. FILIACIN
Apellidos y Nombres: ________________________________________________________________________________________
Edad: __________ Sexo: _________Raza: _______________________Color de Piel: ______________________________________
F. de Nacimiento: ___________________ Lugar de Nac.: ________________________Idioma: ______________________________
Nacionalidad: ________________ Procedencia: _____________ Estado Civil: ____________________________________________
Profesin u Ocupacin: ________________________ Donde Trabaja: __________________________________________________
Direccin: __________________________________________________________________________________________________
Telfono / Celular: ___________________________________________________________________________________________

1.2 ENFERMEDAFD ACTUAL

Motivo de consulta (Sntoma principal) ___________________________________________________________________________
___________________________________________________________________________________________________________
Tiempo de la Enfermedad: _____________________________________________________________________________________
Curso de la enfermedad: _______________________________________________________________________________________
Signos y sntomas principales: ___________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Relato de la Enfermedad: ______________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Funciones Biolgicas (apetito, sed, sueo, Diuresis, sudoracin, Deposiciones): ___________________________________________
___________________________________________________________________________________________________________
1.3 ANTECEDESTES PERSONALES
Generales: (inmunizaciones, hbitos, vivienda, alimentacin, higiene, condicin socioeconmica)_____________________________
Fisiolgicos: (menstruacin, gestacin)____________________________________________________________________________
Patolgicos: _________________________________________________________________________________________________
Familiares: __________________________________________________________________________________________________
Odontolgicos: ______________________________________________________________________________________________
___________________________________________________________________________________________________________
II. EXAMEN CLNICO
2.1 EXAMEN CLNICO GENERAL: (impresin general, estado de hidratacin, nutricin, emocional; LOTEP, peso, talla, grado de colaboracin
,tipo constitucional)_____________________________________________________________________________________________
_________________________________________________________________________________________________________________
2.2SIGNOS VITALES:(PA,FR,T,Pulso)________________________________________________________________________________
2.3 EXAMEN CLNICO REGIONAL:
Extraoral (piel y anexos, forma de crneo y cara, perfil anteroposterior, simetra facial, tono muscular, ATM, labios, fonacin,
respiracin, visin, audicin, sistema linftico, deglucin)_____________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Intraoral: (apertura bucal, frenillos, carrillos, fondo de surco, paladar, piso de boca, lengua, orofaringe, glndulas y conductos
salivales, encas, higiene oral)
__________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________

N DE
DIENTE

Estado de Salud periodontal

1.8
1.7
1.6
1.5/5.5
1.4/5.4
1.3/5.3
1.2/5.2
1.1/5.1
2.1/6.1
2.2/6.2
2.3/6.3
2.4/6.4
2.5/6.5
2.6
2.7
2.8
3.8
3.7
3.6
3.5/7.5
3.4/7.4
3.3/7.3
3.2/7.2
3.1/7.1
4.1/8.1
4.2/8.2
4.3/8.3
4.4/8.4
4.5/8.5
4.6
4.7
4.8
OBSERVACIONES:

DI-S y CI-S
ndice de HO-S

Oclusin(Segn Angle)

DESCRIPCIN

CPO-D

Registro de Prtesis
Exmenes Complementarios

TRATAMIENTOS A REALIZAR

FECHA

PRESUPUESTO

TRATAMIENTO

ADELANTO

FECHA

CITA