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CLINICA ODONTOLOGICA NATURAL – DENT C.D.JONHNY ALBERTO VALDEZ AGUIRRRE CED. PROF 7801081 Odontología Integral HISTORIA CLINICA Nombre del paciente.__________________________________________ Edad._______________________ Domicilio._________________________________________________________________________________ Tel._______________ Móvil._______________ Mail.___________________

Estado civil._____________

Ocupación.___________________ Grado de estudios.__________________ Red. Social_________________ Medico familiar.____________________________________________________________________________ Motivo de la consulta Odontologica._________________________________________________________

ANTECEDENTES PATOLOGICOS HEREDOFAMILIARES Madre.___________________________________________________________________________________ Padre.___________________________________________________________________________________ Hermanos.________________________________________________________________________________ Hijos.____________________________________________________________________________________ Esposo(a).________________________________________________________________________________ Otros.____________________________________________________________________________________

ANTECEDENTES PATOLOGICOS PERSONALES Enfermedades inflamatorias e infecciosas no transmisibles._________________________________________ ETS_____________________________________________________________________________________ Enfermedades neoplásicas.___________________________________________________________________ Enfermedades congénitas.___________________________________________________________________ Otras.____________________________________________________________________________________ Con que frecuencia se lava los dientes__________________________________________________________ Utiliza auxiliares de higiene bucal SI ( )

NO ( ) Cuales.________________________________________

Consume golosinas u otro tipo de alimentos entre comidas SI ( Cuenta con todas sus vacunas SI ( Adicciones. Tabaco (

)

)

Alcohol (

NO ( )

)

NO (

)

) Cual falta.________________________________________

CLINICA ODONTOLOGICA NATURAL – DENT C.D.JONHNY ALBERTO VALDEZ AGUIRRRE CED. PROF 7801081 Odontología Integral Antecedentes alérgicos. Analgésicos ( ) Antibióticos ( ) Anestésicos (

) Alimentos ( )

Especifique._______________________________________________________________________________ Ha sido hospitalizado. SI (

)

NO (

)

Fecha.__________________

Motivo.___________________________________________________________________________________ Padecimiento actual.________________________________________________________________________ Interrogatorio por aparatos y sistemas Aparato digestivo.__________________________________________________________________________ Aparato respiratorio.________________________________________________________________________ Aparato cardiovascular.______________________________________________________________________ Aparato genitourinario._______________________________________________________________________ Sistema endocrino._________________________________________________________________________ Sistema hematopoyético._____________________________________________________________________ Sistema nervioso___________________________________________________________________________ Sistema musculoesqueletico._________________________________________________________________ Sistema tegumentario._______________________________________________________________________ Peso._______________ Talla._______________ Complexión._______________ Signos vitales FC.______

TA._______

FR.________ T.__________

Exploración de cabeza cuello._______________________________________________________________ ________________________________________________________________________________________ Articulación Temporomandibular.______________________________________________________________ ________________________________________________________________________________________ Tejidos blandos.___________________________________________________________________________ _________________________________________________________________________________________ Periodonto.________________________________________________________________________________ _________________________________________________________________________________________ Interpretación radiográfica.___________________________________________________________________ ________________________________________________________________________________________ Estudios de laboratorio y gabinete.____________________________________________________________

CLINICA ODONTOLOGICA NATURAL – DENT C.D.JONHNY ALBERTO VALDEZ AGUIRRRE CED. PROF 7801081 Odontología Integral Diagnostico.______________________________________________________________________________ _________________________________________________________________________________________

___________________________ Nombre y firma del paciente

____________________________ Nombre y firma del Odontólogo

CLINICA ODONTOLOGICA NATURAL – DENT C.D.JONHNY ALBERTO VALDEZ AGUIRRRE CED. PROF 7801081 Odontología Integral

Plan de tratamiento O. preventiva.______________________________________________________________________________ Endodoncia.______________________________________________________________________________ Operatoria._______________________________________________________________________________ Cirugia.__________________________________________________________________________________ Protesis._________________________________________________________________________________

Odontograma de evolución

CLINICA ODONTOLOGICA NATURAL – DENT C.D.JONHNY ALBERTO VALDEZ AGUIRRRE CED. PROF 7801081 Odontología Integral NOTA DE EVOLUCION _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________