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Uploaded on
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2023/2024

Como evaluar a un paciente correctamente

Institution
Ubbj
Course
Propedéutico (23222023)

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UNIVERSIDADBIENESTARBENITOJUAREZUBBJHISTORIACLINICA

HISTORIACLINICA

FECHAYHORQA DELEGACION MOTIVODECONSULTA


NOMBREQUIENELABORA

Nexpediente

FICHADEIDENTIFICACIÓN
TIPODEDOCUMENTO

NOMBREDELPACIENTE
FECHADENACIMIENTOGRUPOÉTNICO

SEXO EDAD
DATOSDELACOMPAÑANTE

NOMBRECOMPLETO
PARENTESCO



ATECEDENTESFAMILIARES
PADRE MADRE:
OTRO:

ANTECEDENTESHEREDO-FAMILIARES

ABUELOS
PATERNOS Enfermedades
hereditarias
ABUELOS
MATERNOS Enfermedades
ecogénicas
PADRES
Enfermedades
depredisposiciónfa
HERMANOS miliar
Enfermedades
familiares
CÓNYUGEOPA
REJA Nosedetecto
HIJOS

, UNIVERSIDADBIENESTARBENITOJUAREZUBBJHISTORIACLINICA

ANTECEDENTESPERSONALESNOPATOLÓGICOS ANTECEDENTESPERSONALESPATOLÓGICOS

1. Hábitosalimentarios Toxicológicos
Alcoholismo sinoTabaquismo
sinoDrogadicción sino
2. Vivienda
Quirúrgicos _

3. Hábitoshigiénicos
Traumatismos _
_
4. Hábitosrecreativos

Transfusionales _
_
5. Inmunizaciones

Alérgicos
_
6. Otro:
Infectocontagioso
_

DATOSHEMATOLOGICOS
GRUPOSANGUIN RH:
EO:




ANTECEDENTESGINECO-
OBSTETRICOS
MENARQUÍA: PUBARQUÍA:
TELARQUÍA: MENOPAUSIA:
FECHADEULTIMAMENSTRUACIÓN: CICLOSMENS
TRUALES
DURACIÓN: INICIOVIDASEXUAL:
PLANIFICACIÓN TIPODEPLANIFICADOR:
MASTOGRAFIA
USG


FICHAGINECO–OBSTETRICA
GESTACIÓN: ABORTOS:
PARTOS: VIVOS:
CESÁREAS: MUERTOS:
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Ubbj
Course
Propedéutico (23222023)
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Uploaded on
October 13, 2023
Number of pages
7
Written in
2023/2024
Type
PRESENTATION
Person
Unknown

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