This document contains a pediatric clinical history form with sections for patient affiliation details, reason for consultation, history of current illness, personal and family medical histories, immunization history, perinatal history, physical examination findings, and presumed diagnoses. It collects information such as the patient's name, age, address, motivation for consultation, habits, development, schooling, allergies, group and Rh factor, pregnancy and birth details, parents' medical histories, systems review, vital signs, physical exam findings, and five potential diagnoses.

1. HISTORIA CLINICA PEDIATRICA
AFILIACIÓN
Nombre completo______________________________________________________________
Edad _______________________fecha de nacimiento_______________________________
Sexo_________________________ Dirección ________________________________________
Datos obtenidosde__________________________Confiabilidad_________________________
MOTIVO DE CONSULTA
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
HISTORIA DE LA ENFERMEDAD ACTUAL
_____________________________________________________________________________
_____________________________________________________________________________
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ANTECEDENTES PERSONALES PATOLÓGICOS
_____________________________________________________________________________
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ANTECEDENTES PERSONALES NO PATOLÓGICOS
Hábitospersonales _____________________________________________________________
Lactancia Materna Artificial Mixta
Ablactación ___________________________________________________________________
Alimentación__________________________________________________________________
Alergias ______________________________________________________________________
Grupo y factor Sanguíneo________________________________________________________
Otros ________________________________________________________________________
_____________________________________________________________________________
DesarrolloPsicomotor
Sonrió Sostuvocabeza Se sentó
Se paró Caminosolo
Control de esfíntervesical anal
Escolaridadactual______________________________________________________________
Otros_________________________________________________________________________
_____________________________________________________________________________
Inmunización
BCG__________________________________ Polio_______________________________
Pentavalente___________________________ Rotavirus____________________________
Antineumococica________________________ Influenzaestacional___________________
SRP Antiamarillica
Otras ______________________________________________________________________

2. ANTECEDENTES PERINATALES
Productode embarazoNº_____________ de ________________ semanas de gestación
Sitiode nacimiento_________________________________________________________
Tipode Parto Vaginal /Cesárea por que________________________________________
Datos al nacimiento:Peso____________ Talla_____________ PC___________________
APGAR_____________________________
Problemasal nacimiento_________________________________________________________
_____________________________________________________________________________
ANTECEDENTES FAMILIARES
Nombre completomadre _______________________________________________________
Edad Hábitos
Grupo sanguíneo
G P C A
Gineco-obstetricos _____________________________________________________________
_____________________________________________________________________________
Ant. Patológicos________________________________________________________________
_____________________________________________________________________________
Nombre completoPadre _________________________________________________________
Edad Hábitos
Grupo sanguineo
Ant.Patológicos________________________________________________________________
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Otros_familiares________________________________________________________________
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ANAMNESISPOR SISTEMAS
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EXAMEN FISICO
EXAMEN FISICO GENERAL
_____________________________________________________________________________
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FC FR Tº PA
PESO TALLA IMC

3. EXAMEN FISICOSEGMENTARIO
Cabeza_______________________________________________________________________
_____________________________________________________________________________
ojos__________________________________________________________________________
orejas________________________________________________________________________
nariz_________________________________________________________________________
Boca_________________________________________________________________________
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Cuello________________________________________________________________________
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Torax_________________________________________________________________________
_____________________________________________________________________________
Corazón______________________________________________________________________
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Pulmones_____________________________________________________________________
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Abdomen_____________________________________________________________________
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Extremidades_________________________________________________________________
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Genitourinario_________________________________________________________________
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Neurológico___________________________________________________________________
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DIAGNOSTICOPRESUNTIVO
1. _______________________________________________________________________
2. _______________________________________________________________________
3. _______________________________________________________________________
4. _______________________________________________________________________
5. _______________________________________________________________________
Elaboradopor: ______________________