MODELO DE Hist. Clinica Nau

DATOS DE LA HISTORIA
N° DE HISTORIA: __________________________. FECHA: _____________________.
CENTRO DE REHABILITACION:_____________________________________________.
FISIOTERAPEUTA:
_________________________________________________________.
DATOS DEL PACIENTE
NOMBRES: _________________________. APELLIDOS: ________________________.
C.I. : ___________________. FECHA DE NACIMIENTO: _________________________.
SEXO: _________. EDAD: _________. PESO: _________. ESTATURA:__________.
TELEFONOS: ___________________________________________________________.
DOMICILIO: _____________________________________________________________.
PROFESION: ____________________________. OTRAS ACTIVIDADES: ___________
____________________________. DEPORTE: _________________________________.
ANTECENDTES FAMILIARES
ACV/ECV: _____________. HTA/PAB: ______________. DIABETES: _______________.
ETS: _____________________________. ALERGIAS: ___________________________.
PSICOLÓGICOS: ________________________________________________________.
ANTECENDTES PATOLOGICOS.
ANTECEDENTES PATOLÓGICOS DIRECTOS: _________________________________
_______________________________________________________________________.
ACV/ECV: _____________. HTA/PAB: ______________. DIABETES: _______________.
ETS: _____________________________. ALERGIAS: ___________________________.
PSICOLÓGICOS: ________________________________________________________.
ANTECENDENTES FARMACOLÓGICOS
FARMACOS: _____________________________________________________________
________________________________________________________________________
_______________________________________________________________________.
HABITOS
TABAQUISMO: ___________. ALCOHOLISMO: ___________. DROGAS: ___________.
CAFÉ: _____________. AZÚCARES: ______________. OTROS: ________________.
DIAGNÓSTICOS
DIAGNÓSTICO EN FISIOTERAPIA: __________________________________________
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
PLAN DE TRATAMIENTO
TRATAMIENTO: __________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________.
OBJETIVOS
________________________________________________________________________
_______________________________________________________________________.
________________________________________________________________________
_______________________________________________________________________.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________.
OBSERVACIONES Y RECOMENDACIONES
OBSERVACIONES: _______________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________.
RECOMENDACIONES: ____________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

MODELO DE Hist. Clinica Nau

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MODELO DE Hist. Clinica Nau

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DATOS DE LA HISTORIA

N° DE HISTORIA: ______. FECHA: _.

DATOS DEL PACIENTE

NOMBRES: _. APELLIDOS: .

C.I. : _. FECHA DE NACIMIENTO: _______.

SEXO: _____. EDAD: _. PESO: _. ESTATURA:______.

PROFESION: __________________. OTRAS ACTIVIDADES: _

. DEPORTE: _____.

ACV/ECV: _. HTA/PAB: . DIABETES: _____.

ETS: ___. ALERGIAS: _.

ANTECEDENTES PATOLÓGICOS DIRECTOS: _________________________________

ACV/ECV: _. HTA/PAB: . DIABETES: _____.

ETS: ___. ALERGIAS: _.

TABAQUISMO: _____. ALCOHOLISMO: _. DROGAS: _______.

CAFÉ: _. AZÚCARES: . OTROS: ______.

DIAGNÓSTICO EN FISIOTERAPIA: __________________________________________

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