ANEXO HISTORIA CLNICA

ODONTOLOGA
REHABILITACIN ORAL
CONSULTA EXTERNA
UNIDAD DE SALUD ORAL

Cdigo: CEX-FO-323-005

Versin: 1

FECHA: ________________________
No. CONSECUTIVO SISTEMA: _________________
NOMBRE: ___________________________________ DOCUMENTO IDENTIDAD: __________________
DIRECCIN: ______________________________ TELFONO: ________________________________
MOTIVO DE LA CONSULTA:
___________________________________________________________________________________________________
__________________________________________________________________________________________________
HISTORIA ENFERMEDAD ACTUAL :
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
DIAGNSTICO PRESUNTIVO :
______________________________________________________________________________________________
______________________________________________________________________________________________
DIAGNSTICO DEFINITIVO:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________
LECTURA DE MEDIOS DIAGNSTICOS:
______________________________________________________________________________________________
______________________________________________________________________________________________
__________________________________________________________________________________________
PRONSTICO :
______________________________________________________________________________________________
______________________________________________________________________________________________
PLAN DE TRATAMIENTO :
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
__________________________________________________________________________________________

______________________________
FIRMA DEL PROFESIONAL

________________________________
FIRMA DEL PACIENTE O ACUDIENTE

ODONTOGRAMA DE EVOLUCIN CONVENCIONES:

Diente Obturado (azul) Amalgama: lleno
Resina o carilla: rayado
Metal Porcelana : delineado

Pgina 1 de 2

ANEXO HISTORIA CLNICA

ODONTOLOGA
REHABILITACIN ORAL
CONSULTA EXTERNA
UNIDAD DE SALUD ORAL

Cdigo: CEX-FO-323-005

Versin: 1

NOTAS DE EVOLUCIN
Fecha y Hora:

RECOMENDACIONES POSTRATAMIENTO :
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
CONTROLES :
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
SE ENTREGA CONTRAREFERENCIA AL PACIENTE : SI___ NO___
SE ENTREGAN MEDIOS DIAGNSTICOS AL PACIENTE :

SI___ NO___

FIRMA PACIENTE QUE HACE CONSTAR HABERLOS RECIBIDO :__________________________________

Pgina 2 de 2