HISTORIA CLINICA ODONTOLOGICA

FILIACION

Nombres y Apellidos completos: ____________________________________________________________

Numero de Historia Clínica: _______________ Número de DNI: __________________________________
Fecha y Hora de la atención: _______________________________________________________________
Fecha de apertura de la Historia Clínica: ______________________________________________________

Sexo: _____ Edad: ______ Lugar de nacimiento: _______________ Fecha de nacimiento: ____________
Grado de instrucción: ____________ Raza: ______________ Ocupación: ____________________________
Religión: _______________________ Estado Civil: _____________________________________________

Lugar de procedencia: _____________________________________________________________________

Domicilio actual: _________________________________________________________________________
Nombre y apellido del acompañante: __________________________________________________________
Ultima visita al odontólogo: _________________________________________________________________

ENFERMEDAD ACTUAL:

Datos del informante: ______________________________________________________________________

Motivo de consulta:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Tiempo de enfermedad: ____________________________________________________________________
Signos y síntomas principales:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Relato Cronológico: _______________________________________________________________________
Funciones Biológicas: _____________________________________________________________________

ANTECEDENTES

Antecedentes Familiares:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Antecedentes Personales:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

EXPLORACION FISICA

Signos Vitales

PA: ___________ PULSO: ___________ TEMP: ______________ FC: ____________ FR: ___________

Examen clínico general: ___________________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________

Examen clínico Odontoestomatologico:

_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

DIAGNOSTICO CIE 10

Diagnostico presuntivo: ____________________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________

Diagnóstico Definitivo: _____________________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

PLAN DE TRABAJO
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

PRONOSTICO
_______________________________________________________________________________________
_______________________________________________________________________________________

TRATAMIENTO/RECOMENDACIONES (Nombre genérico del medicamento, dosis, vía de administración,

tiempo de administración, cuidados, medios higienicos-dieteticas, preventivas)
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

ALTA DEL PACIENTE

_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

____________________________

Nombre y Apellidos del profesional

Sello y Firma