HISTORIA CLÍNICA INGLES

Formato de historia clínica en idioma inglés

Identification

Patient’s name:

Age:

Gender:

Place and date of birth:

Occupation:

Marriage status:

Address:

Phone:

e-mail:

Type of interview:

Informant:

Liability:

Hall:

Room:

Bed:

Date of admission:

Date when history was made:

Doctor’s data:

Family history

Ascendents:

Siblings and partner:

Descendents:

Past medical and surgical history

Childhood diseases (measles, mumps, rubella, poliomielitis, diphteria, pertussis, meningitis, others):

Chronic and episodic illnesses:

Previous hospitalizations:

Operations and injuries:

Allergy:

Medication intolerances:

Immunizations:Gynecological history

Menarche:

Date of last period:

Rhythm:

Menopause:

Sexually transmitted diseases:

Leukorrhea:

PAP test:

Mammography:

Pregnancies:

Deliveries:

C-sections:

Abortions:

Fertility problems:

Personal non pathological history and social history

Smoke:

Alcoholism:

Drug addictions:

Tattoos:

Medications:

Birthplace:

Residence place:

Characteristics of the house:

Occupation:

Marital status:

Education:

Schooling:

Socioeconomic status:

Religion:

Entertainments:

Physical activity:

Weight:

Height:

Body mass index:

Diet quality (balanced or unbalanced):

Caloric real intake and caloric ideal intake:

Sexual activity:Sexual preference:

Relationships:

Attitude towards the disease

Interpretation of the previous information (risk factors)

Chief Complaints (symptoms which made the patient ask for medical attention, specifying the

duration of each manifestation)

Present Illness

Data of medical interest of the ill person (risk factors)

List of the manifestations (symptoms, signs and data of studies of laboratory and special studies,

written down in chronological order of appearance)

Semiology of the manifestations (symptoms, signs, special data of laboratory and studies)

Relevant negative and positive data that have relation with the present illness (symptoms, signs of

physical exploration, and data of laboratory and special studies)

Present Illness (synthesis of the information in chronological order)

Review of systems

General symptoms:

Integument:

Lymph nodes:

Bones, joints and muscles:

Hematopoietic system:

Endocrine system:

Allergic and immunologic history:

Head:

Eyes:

Ears:

Nose:

Mouth:

Throat:

Neck:

Breasts:

Respiratory system:

Cardiovascular system:

Gastrointestinal system:

Genitourinary system:

Nevous system:

Psychiatric history:

Physical ExaminationGeneral inspection

Somatometry and Vital Signs:

Weights:

Heights:

Body mass index:

Index waist/hip

Blood pressure:

Cardiac frequency:

Respiratory frequency:

Pulse:

Temperature: