CLINICA ODONTOLOGICA NATURAL DENT

C.D.JONHNY ALBERTO VALDEZ AGUIRRRE

CED. PROF 7801081
Odontologa Integral
HISTORIA CLINICA
Nombre del paciente.__________________________________________ Edad._______________________
Domicilio._________________________________________________________________________________
Tel._______________ Mvil._______________ Mail.___________________

Estado civil._____________

Ocupacin.___________________ 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 neoplsicas.___________________________________________________________________
Enfermedades congnitas.___________________________________________________________________
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
Odontologa Integral
Antecedentes alrgicos. Analgsicos ( ) Antibiticos ( ) Anestsicos (

) 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 hematopoytico._____________________________________________________________________
Sistema nervioso___________________________________________________________________________
Sistema musculoesqueletico._________________________________________________________________
Sistema tegumentario._______________________________________________________________________
Peso._______________ Talla._______________ Complexin._______________
Signos vitales FC.______

TA._______

FR.________ T.__________

Exploracin de cabeza cuello._______________________________________________________________

________________________________________________________________________________________
Articulacin Temporomandibular.______________________________________________________________
________________________________________________________________________________________
Tejidos blandos.___________________________________________________________________________
_________________________________________________________________________________________
Periodonto.________________________________________________________________________________
_________________________________________________________________________________________
Interpretacin radiogrfica.___________________________________________________________________
________________________________________________________________________________________
Estudios de laboratorio y gabinete.____________________________________________________________

CLINICA ODONTOLOGICA NATURAL DENT

C.D.JONHNY ALBERTO VALDEZ AGUIRRRE
CED. PROF 7801081
Odontologa Integral
Diagnostico.______________________________________________________________________________
_________________________________________________________________________________________

___________________________
Nombre y firma del paciente

____________________________
Nombre y firma del Odontlogo

CLINICA ODONTOLOGICA NATURAL DENT

C.D.JONHNY ALBERTO VALDEZ AGUIRRRE
CED. PROF 7801081
Odontologa Integral

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

Odontograma de evolucin

CLINICA ODONTOLOGICA NATURAL DENT

C.D.JONHNY ALBERTO VALDEZ AGUIRRRE
CED. PROF 7801081
Odontologa Integral
NOTA DE EVOLUCION
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________