HISTORIA ODONTOLOGICA

No. HISTORIA CLINICA

Ciudad y Fecha: _________________________________________

I. DATOS PERSONALES

NOMBRE Y APELLIDOS:

TIPO Y NÚMERO DE DOCUMENTO: FECHA DE NACIMIENTO - EDAD

SEXO ESTADO CIVIL OCUPACION No. TELEFONO

DIRECCION No. CELULAR

NOMBRE ACUDIENTE RELACION CON EL PACIENTE TELEFONO

II. MOTIVO DE CONSULTA _________________________________________________________________________

______________________________________________________________________________________________________
______________________________________________________________________________________________________
III. ANTECEDENTES PERSONALES
SI NO OBSERVACIONES

SISTEMA RESPIRATORIO
______________________________________________________
DIABETES ______________________________________________________
HEPATITIS ¿CUÁL?_______________________________________________
FIEBRE REUMATICA _______________________________________________________
ACCIDENTES/TRAUMAS _______________________________________________________
HOSPITALIZACIONES _______________________________________________________
CIRUGIAS _______________________________________________________
ALERGIAS _______________________________________________________
S. CARDIOVASCULAR _______________________________________________________
COAGULACION _______________________________________________________
EMBARAZO _______________________________________________________
HABITOS _______________________________________________________
MEDICACION ACTUAL _______________________________________________________
ENF. TRANSMISION SEXUAL _______________________________________________________
VIH _______________________________________________________
OTROS ¿CUÁL?________________________________________________

ANTECEDENTES FAMILIARES ___________________________________________________________________________

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IV. EXAMEN CLINICO

NORMAL ANORMAL OBSERVACIONES

LABIOS ______________________________________________________
CARRILLOS ______________________________________________________
LENGUA ______________________________________________________
PALADAR DURO/ BLANDO ______________________________________________________
PISO DE BOCA ______________________________________________________
FRENILLOS ______________________________________________________
MUCOSA ORAL ______________________________________________________
MAXILAR SUPERIOR ______________________________________________________
MAXILAR INFERIOR
______________________________________________________
PROCESO ALVEOLAR
______________________________________________________

OCLUSION_____________________________________________________________________________________________
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HÁBITOS DE HIGIENE ORAL

SI NO
VISITA AL ODONTÓLOGO ¿CUÁNTAS VECES?________________________________________
HIGIENE ORAL (PROFILAXIS) ¿HACE CUÁNTO?__________________________________________
CEPILLADO AL DÍA ¿CUÁNTAS VECES?________________________________________
SEDA DENTAL ¿CUÁNTAS VECES?________________________________________
ENJUAGUE BUCAL ¿CUÁNTAS VECES?________________________________________

A.T.M.
NORMAL ANORMAL OBSERVACIONES
PALPACION MUSCULAR
______________________________________________
VOLUMEN MUSCULAR
______________________________________________
APERTURA
______________________________________________

OBSERVACIONES______________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________

HÁBITOS ORALES SI NO
RESPIRADOR ORAL
QUEILOSFAGIA
SUCCIÓN DIGITAL
ONICOFAGIA
OTROS ¿CUÁL? _____________________________________________________________

V. INDICE DE PLACA

HISTORIA DE CARIES INICIAL

NUMERO DE DIENTES:
CARIADOS: ________ OBTURADOS: ____________ PERDIDOS: ______________ TOTAL COP: ___________________

HISTORIA DE CARIES FINAL

NUMERO DE DIENTES:
CARIADOS: ________ OBTURADOS: ____________ PERDIDOS: ______________ TOTAL COP: ___________________

ANALISIS PERIODONTAL
NORMAL ANORMAL OBSERVACIONES
REBORDE MARGINAL
______________________________________________________
COLOR ______________________________________________________
SI NO OBSERVACIONES
PLACA BLANDA ______________________________________________________
PLACA CALCIFICADA ______________________________________________________
SANGRADO ______________________________________________________
VI. ODONTOGRAMA

18 ____________________________________________ 38 ____________________________________________
17 ____________________________________________ 37 ____________________________________________
16 ____________________________________________ 36 ____________________________________________
15 ____________________________________________ 35 ____________________________________________
14 ____________________________________________ 34 ____________________________________________
13 ____________________________________________ 33 ____________________________________________
12 ____________________________________________ 32 ____________________________________________
11 ____________________________________________ 31 ____________________________________________
21 ____________________________________________ 41 ____________________________________________
22 ____________________________________________ 42 ____________________________________________
23 ____________________________________________ 43 ____________________________________________
24 ____________________________________________ 44 ____________________________________________
25 ____________________________________________ 45 ____________________________________________
26 ____________________________________________ 46 ____________________________________________
27 ____________________________________________ 47 ____________________________________________
28 ____________________________________________ 48 ____________________________________________

OBSERVACIONES______________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________

CONVENCIONES
OBTURADO/RESTAURACIÓN (RESINA O AMALGAMA) AZUL
CARIADO ROJO
 RESTAURACIÓN DEFECTUOSA HALO ROJO Y RELLENO AZUL
SELLANTE S AZUL
SELLANTE DEFECTUOSO S ROJA
AUSENTE / EXTRAÍDO LÍNEA NEGRA VERTICAL
EN ERUPCIÓN FLECHA NEGRA

VII. DIAGNÓSTICO DEFINITIVO

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VIII. PLAN DE TRATAMIENTO

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____________________________________ _________________________________________
NOMBRE Y FIRMA DEL PACIENTE NOMBRE Y FIRMA DEL ESTUDIANTE

________________________________________
NOMBRE Y FIRMA DEL ODONTÓLOGO

IX. ODONTOGRAMA FINAL

OBSERVACIONES
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X. EVOLUCIÓN
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