HISTORIA CLINICA DE EMERGENCIA

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Modelo de Historia Clinica-

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HISTORIA CLINICA DE EMERGENCIA

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N°HCL: ___________________ ___________________ HORA: _________ FECHA : ___________________ ___________________ I.- ANAMNESIS: 1.- Datos de Filiación:

Nombres y Apellidos: _____________________________________________________________

Lugar de Nacimiento:______________________________________________________________

Fecha de Nacimiento: _____________________________________________________________ Edad Domicilio actual

: ______________

Sexo : _________________ _________________

:___________________ :________ _________________________ _______________________________ _____________________________ ____________

Domicilio de Procedencia: __________________________________________________________

Documento de Identidad : _________________________________________________________ N° del Seguro

:_______________________ :_________ ________________ __

Estado Civil

: ________________________ _________________________ _

Grado de Intrución : ________________________ __________________________ __ Ocupación Ocupación

: __________________________ __________________________

Religión

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Nombre y DNI del Acompañante: _____________________________ _____________________________________ ___________________ _______________ ____

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2.-ENFERMEDAD ACTUAL: Tiempo Enfermedad : __________

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Forma de Inicio : _ ____________

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FUNCIONES BIOLOGICAS:

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APETITO : __________________ __________________

SED :__________________ :__________________ SUEÑO: ____________________ ____________________

DEPOSICIONES:___________ DEPOSICIONES:___________________ _____________ _____

ORINA : _________________________ _________________________________ ________

3.-ANTECEDENTES:

a.- Antecedentes Generales:________________________________________________________

_______________________________________________________________________________

b.- Antecedentes Antecedentes Familiares: Familiares: _______________________________________________________

________________________________________________________________________________ ________________________________________________________________________________ c.- Antecedentes Personales :

________________________________________________________________________________ ________________________________________________________________________________ d.- Antecedentes Patologicos-

________________________________________________________________________________ ________________________________________________________________________________ e.- Antecedentes Fisiologicos:______________________________________________________

________________________________________________________________________________ ________________________________________________________________________________

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Antecedentes

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Examen fisico Examenes auxiliares Diagnostico presuntivo Plan de trabajo Terapeutica y seguimiento Fecha y hora Firma y sello del medico tratante

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