This document contains a clinical history form for a patient, collecting information about their family medical history, personal medical history, current complaints, and physical exam findings. Sections include ancestry, habits, gynecological history, review of symptoms by body system, and vital signs. The physical exam section documents the general impression and assessments of head, neck, and other body areas.

1. Programa de Enseñanza Clínica Complementaria
HISTORIA CLINICA
FICHA DE IDENTIFICACION:
Nombre:____________________________________________________Edad:___________Sexo:________
Ocupación:________________Estado Civil:_____________Nacionalidad:____________________________
Residencia_____________________Escolaridad:________________________Religión:_________________
Servicio:________________________Cama:________ No. Expediente:______________________________
ANTECEDENTES HEREDOFAMILIARES:
Padres: ........................Vivos: ................................Fallecidos:..............................................................................
…………………………
……Causas:..................................................................................
Hermanos:....................Vivos:................................Fallecidos:..............................................................................
…………………………
…… Causas:..................................................................................
Hijos:............................Vivos:..................................Fallecidos:............................................................................
Causas:……............................................................................
Diabetes Mellitus tipo 2 SI ⃝ NO ⃝ __________________________________________________________
Hipertensión Arterial
SI ⃝ NO ⃝ __________________________________________________________
Tuberculosis
SI ⃝ NO ⃝ __________________________________________________________
Cáncer
SI ⃝ NO ⃝ __________________________________________________________
Otras (especificar)
SI ⃝ NO ⃝ __________________________________________________________
ANTECEDENTES PERSONALES NO PATOLOGICOS:
1) Hábitos Tóxicos:
Alcohol: __________________________Tabaco:_________________________Drogas:_________________
2) Fisiológicos:
Alimentación:____________________________________________________________________________
Dipsia:__________________________________________________________________________________
Diuresis: ________________________________________________________________________________
Catarsis:_________________________________________________________________________________
Somnia:_________________________________________________________________________________
Otros:__________________________________________________________________________________
ANTECEDENTES PERSONALES PATOLOGICOS:

2. Infancia:_________________________________________________________________________________
Adulto:__________________________________________________________________________________
Diabetes Mellitus tipo 2 SI ⃝ NO ⃝ __________________________________________________________
Hipertensión Arterial
SI ⃝ NO ⃝ __________________________________________________________
Tuberculosis
SI ⃝ NO ⃝ __________________________________________________________
Cáncer
SI ⃝ NO ⃝ __________________________________________________________
Otras (especificar)
SI ⃝ NO ⃝ __________________________________________________________
Quirúrgicos:______________________________________________________________________________
Traumatológicos:_________________________________________________________________________
Alérgicos: _______________________________________________________________________________
Otros: __________________________________________________________________________________
GINECO-OBSTÉTRICOS:
FUM:
/
/
FPP:
/
/
EDAD GESTACIONAL:
semanas.
Menarca:_______RM (Rit. Menstr)____/___ IRS____Nº de parejas____Flujo genital____________________
Gestas:.............Partos:.............Cesáreas:...............Abortos: ____________ Anticonceptivos: SI ⃝ NO ⃝
Tipo: ______________________ Tiempo: __________Última toma: ________________________________
Cirugías ginecológicas (especificar)___________________________________________________________
Otros: __________________________________________________________________________________
PADECIMIENTO ACTUAL
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3. INTERROGATORIO POR APARATOS Y SISTEMAS
Aparato respiratorio:
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Aparato digestivo:
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Aparato cardiovascular:
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Aparato renal y urinario:
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Aparato genital:
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Sistema endocrino:
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Sistema hematopoyético y linfático:
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Piel y anexos:
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Musculo esquelético:
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Sistema nervioso:
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4. ________________________________________________________________________________________
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Órganos de los sentidos:
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Síntomas generales:
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EXPLORACIÓN FÍSICA:
Impresión General: _______________________________________________________________________
Signos Vitales: FC__________TA:_________FR: _______PULSO:____________ TEMPERATURA: _________
Peso actual: ________Talla: __________BMI:___________
Inspección general:
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Cabeza:
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Cuello:
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Tórax:
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5. ________________________________________________________________________________________
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Abdomen:
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Tacto vaginal y rectal:
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Extremidades:
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Exploracion neurológica:
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EXAMENES COMPLEMENTARIOS:
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DIAGNOSTICO PRESUNTIVO:
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PLAN TERAPÉUTICO:
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NOMBRE, CEDULA Y FIRMA DEL MEDICO
TRATANTE:_______________________________________________________________________________