Ficha Clnica

1.- Datos Civiles:

Nombre: ____________________________________________________________________________
Gnero: _______________
Estado civil:______________
Ocupacin:______________________________
Fecha de ingreso: _____/______/_____

2.- Anamnesis prxima:

Motivo de la consulta
Historia del motivo de la consulta
Fue derivado? Tratamientos previos en relacin a su problema?
Qu idea tiene usted de la enfermedad?
Dolor? Cundo? (Fecha) Cmo? (Forma de comienzo) Por qu? (Causa desencadenante)
Ubicacin Tipo Intensidad Comienzo Factores Actitud Sintomatologa

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3.- Anamnesis remota personal:

Antecedentes mrbidos?

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Embarazo (trimestre):____________________________________________
Mtodo anticonceptivo: _________________________________________
ETS, VIH: ______________________________________________________

Tabaco (N de cigarros diarios y aos que consume tabaco): ___________________________

Alcohol: (Cantidad, calidad y frecuencia): ______________________________

FRMACOS?
Consume algn frmaco de manera regular? Cules? Dosis? Auto medicado?:

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Historia Odontolgica:

Experiencia dental pasada: ________________________________________________________

Miedo al dentista?: ______________________________________________________________
Anestsicos locales: ______________________________________________________________

4.- Anamnesis remota familiar:

Antecedentes mdicos familiares?:

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Enfermedades hereditarias: (indicar el familiar).

Diabetes: _______________________________________________
Hipertensin arterial: _________________________
Enfermedades cardiovasculares: _________________________
Alteraciones coagulacin: _________________________
Cncer: _________________________
Alergias: _________________________
Causa y edad de muerte de los familiares: _________________________

Observaciones:
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5.- Examen fsico:

a) General
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Estado nutricional:

Talla: ____ mts

Peso: ____ Kg.
Alteraciones : _________________________

Presin arterial y pulso:

1.
Pulso:
2.
Sistlica: ______ mmHg
3.
Diastlica: ______ mmHg
Respiracin: ____ por minuto.
Temperatura: ____ C
b) Segmentario
1.- Cabeza y cuello: Aumento de volumen? Linfonodos? Alteraciones?

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2.- ATM
i.
Dificultad de abrir o cerrar la boca?
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ii.
Dolor al hablar o al masticar? Dnde?, Cundo?, Cmo?
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iii.
Ruidos Articulares: Clic Crepito
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iv.
Salto articular:
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v.
Cefalea, Otalgia
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vi.
Traumas de cabeza y cuello
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vii.
Tratamientos recibidos
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viii.

Dolor msculos cabeza y cuello

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ix.
Bruxismo
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x.
Desviaciones apertura/cierre
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xi.
Palpacin ATM
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Observaciones:
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3.- Cavidad Oral
i.
Labios: ______________________________________________________________________________________
ii.
Surcos vestibulares: ___________________________________________________________________________
iii.
Mejillas: ______________________________________________________________________________________
iv.
Lengua: ______________________________________________________________________________________
v.
Piso de la boca: _______________________________________________________________________________
vi.
Paladar duro: _________________________________________________________________________________
vii.
Paladar blando: _______________________________________________________________________________
viii.
Rebordes maxilares: ___________________________________________________________________________
ix.
Piezas dentarias:
a) Nmero:
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b) Piezas cariadas:
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c) Piezas extradas:
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d) Piezas obturadas:
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e) Agenesias:
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f) Movilidad:

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Rojo por hacer, Azul realizado

4.- Examen periodontal (PSR):
PSR Grupo 1: _________
PSR Grupo 2: _________
PSR Grupo 3: _________

PSR Grupo 4: _________

PSR Grupo 5: _________
PSR Grupo 6: _________

6.- Exmenes complementarios solicitados:

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7.- Resultados exmenes complementarios solicitados:

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8.- Diagnstico:
General
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Dentario
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Periodontal
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Endodntico
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8.- Plan de tratamiento:

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ALTA
Fecha:
Tratamientos realizados:

Firma paciente: _____________________________

Firma profesional: _____________________________