1. Datos personales:
Nombre: _____________________________________________________________
Genero: __________________
Edad: ____________________
Fecha de nacimiento: ___________________________________________________
Ocupación:_______________________________________________
Estado civil: ______________________________________________
Religión:_________________________________________________
Dirección:_______________________________________________________________
Nivel de escolaridad: ____________________________________________________
Nombre del servicio: _____________________________________________________
Numero de cama: _______________________________________________________
Numero de expediente: _________________________________________________
Fecha y hora de ingreso: ________________________________________________
Fecha y hora de historia: _________________________________________________
Datos otorgados por: ____________________________________________________
Confiabilidad de los datos: _______________________________________________

2. Consulta por:____________________________________________________________
Presente enfermedad
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3. Antecedentes patológicos
• Enfermedades de la infancia:
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• Enfermedades de la adolescencia:
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• Enfermedades de la edad adulta:
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• Hospitalizaciones:
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Intervenciones quirúrgicas:
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• Exámenes especiales
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• Alergias:
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• Transfusiones:
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4. Antecedentes no patológicos
• Cafeísmo: ____________________________________________________
• Etilismo: _____________________________________________________
• Tabaquismo:_________________________________________________
• Drogas: ______________________________________________________
• Patrón de sueño: ______________________________________________
• Patrón de micción: ____________________________________________
• Patrón de defecación: __________________________________________
• Alimentación: ________________________________________________
• Hidratación: __________________________________________________
• Inmunizaciones: ______________________________________________
• Antecedentes familiares:
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• Ecológico-social:
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5. EXAMEN FÍSICO
Apariencia general:
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Signos vitales:
- Presión arterial: ______________
- Pulso: ______________________
- Frecuencia cardíaca: ____________
- Frecuencia respiratoria: _________
- Temperatura: _________________
- Peso: ________________________
- Talla: _______________________
- IMC: ____________________

6. - PIEL
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- CABEZA
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- OJOS
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- OÍDOS
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- NARIZ Y SENOS PARANASALES
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7. - BOCA Y GARGANTA
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- CUELLO
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- TORAX
- PULMONAR
INSPECCION:
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PALPACIÓN:
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PERCUSIÓN:
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8. AUSCULTACIÓN:
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- CARDÍACO
INSPECCION:
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PALPACIÓN:
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PERCUSIÓN:
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AUSCULTACIÓN:
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9. - ABDOMEN
INSPECCIÓN:
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AUSCULTACIÓN:
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PERCUSION:
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PALPACIÓN:
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ARTICULACIONES:
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10. ÓSEO:
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MÚSCULAR:
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- EXTREMIDADES
MIEMBRO SUPERIOR:
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MIEMBRO INFERIOR:
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- NEUROLÓGICO
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11. PARES CRANEALES:
I. ___________________________________________________________________
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II. ___________________________________________________________________
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III. ___________________________________________________________________
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IV. ___________________________________________________________________
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V. ___________________________________________________________________
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VI. ___________________________________________________________________
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VII. ___________________________________________________________________
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12. VIII. ___________________________________________________________________
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IX. ___________________________________________________________________
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X. ___________________________________________________________________
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XI. ___________________________________________________________________
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XII. ___________________________________________________________________
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Fuerza Tono Sensibilidad ROT

13. REFLEJOS ESPECIALES:
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DIAGNOSTICO:
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14. COMENTARIO DEL CASO:
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15. UNIVERSIDAD AUTÓNOMA DE SANTA ANA
UNASA
ESCUELA DE MEDICINA
HISTORIA CLINICA
ALUMNO: _________________________________________________________
CÁTEDRA: ________________________________________________________
CATEDRÁTICO: ___________________________________________________
CICLO: ____________
FECHA: _______________________________________