The document contains forms for collecting a patient's personal details, present illness, past medical history, social history, family history, and physical exam findings. It requests information such as the patient's name, gender, date of birth, occupation, religion, address, hospital service, bed number, file number, admission and history dates. For past medical history, it asks about prenatal history, delivery details, neonatal period, immunizations, growth and development milestones. It also contains sections for past medical, surgical, social and family histories, plus vital signs and general exam findings.

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

2. Consulta por: ____________________________________________________________
Presente enfermedad
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3. Antecedentes personales
Historia prenatal:
 Madre De ______ De Edad, G P P A V .
 Enfermedades Durante El Embarazo: .
 Medicamentos: .
 Drogas: .
 Alcohol: .
 Tabaco : .
 Controles Médicos: En .
 Exámenes Realizados: .
Parto
 Fecha: .
 Lugar: .
 Edad Gestacional: .
 Tipo De Parto: .
Antecedentes neonatales
 Respiro Espontáneamente Necesito Reanimación .
 Se Dio De Alta Junto Con La Madre .
Control médico
 En .
 Inmunizaciones: .
 Bcg: .
 Dpt + Hib + Hb Y Opv: .
 Spr: .
 Influenza: .
 Rotavirus: .
Alimentacion
 SMLD Hasta .
 Edad De Ablactación: .
 Jugos, Frutas Y Vegetales: .
 Huevos: .
 Carnes: .

4.  Dieta Actual: .
 Alergias: .
 # Evacuaciones: .
 Estreñimiento: .
Crecimiento Y Desarrollo
 Adecuado Para La Edad .
 Fijación De La Mirada: .
 Sonrisa Social: .
 Junto Las Manos En La Línea Media: .
 Sostuvo Al Cabeza: .
 Dio Vuelta: .
 Se Sentó: .
 Gateo: .
 Camino: .
 Hablo: .
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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5. Intervenciones quirúrgicas:
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• Exámenes especiales
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• Alergias:
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• Transfusiones:
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• Antecedentes familiares:
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• Ecológico-social:
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6. EXAMEN FÍSICO
Apariencia general:
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Signos vitales:
- Presión arterial: ______________
- Pulso: ______________________
- Frecuencia cardíaca: ____________
- Frecuencia respiratoria: _________
- Temperatura: _________________
- Peso: ________________________
- Talla: _______________________
- IMC: ____________________

7. - 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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8. - 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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9. 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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10. - 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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11. HUESOS:
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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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12. Fuerza Tono Sensibilidad ROT

13. DIAGNÓSTICO:
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TRATAMIENTO:
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14. RAZONAMIENTO CLÍNICO:
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15. UNIVERSIDAD AUTÓNOMA DE SANTA ANA
UNASA
ESCUELA DE MEDICINA
HISTORIA CLINICA
ALUMNO: _________________________________________________________
CÁTEDRA: ________________________________________________________
CATEDRÁTICA: ___________________________________________________
CICLO .
FECHA: _______________________________________