ANEXO HISTORIA CLNICA

ENDODONCIA

Cdigo: CEX-FO-323-008

CONSULTA EXTERNA
UNIDAD DE SALUD ORAL

Versin: 3

FECHA: ________________________
HISTORIA CLNICA No. _____________________
NOMBRE:___________________________________________
EDAD:______________________
FECHA DE NACIMIENTO:__________________
OCUPACIN : _____________________________
DOCUMENTO IDENTIDAD :____________________ SEXO: _____________ ESTADO CIVIL : ___________
DIRECCIN : ______________________________ TELFONO : _______________________________
LUGAR RESIDENCIA :________________________ ASEGURAMIENTO: _________________________
NOMBRE ACOMPAANTE:_____________________ PARENTESCO:_____________________________
TELFONO : ______________________
LLEGA SIN ACOMPAANTE :__________________
PROFESIONAL TRATANTE : ______________________________

SINTOMATOLOGA
DOLOR : SI ____
NO_____
CARACTERISTICAS: PROVOCADO ____ INTERMITENTE ____ PALPITANTE _____ CONSTANTE____
LOCALIZADO ____ DIFUSO ____
AREA ANATOMICA : ____________________________________
REFERIDO _____ AREA ANATMICA : ____________________________________
ESPONTANEO :_____
AUMENTA CON :
FRIO _____ CALOR_____ DULCE_____ MASTICACIN _____ PERCUSIN _____ PALPACIN_____
INTENSIDAD: LEVE(1-2-3)_____, MODERADA(4-5-6-7)_____, SEVERA(8-9-10)_____.
EXAMEN CLNICO
INFLAMACIN INTRAORAL _____ INFLAMACIN EXTRAORAL _____ FSTULA _____ MOVILIDAD _____ CARIES
PROFUNDA _____ SIGNOS DE TRAUMA_____ CAMBIO DE COLOR CORONAL _____ DIENTE RESTAURADO EN :
AMALGAMA_____ RESINA_____ IONOMERO_____ METAL COLADO_____CEMENTO TEMPORAL_____
RESPUESTA A FRIO: ALTA_____ RETARDADA_____ ALIVIO_____
RESPUESTA A CALOR: ALTA_____ RETARDADA____ ALIVIO_____
EXAMEN RADIOGRFICO
ANATOMIA RADICULAR : NORMAL_____ DILACERADA_____ CURVA_____
FORMACIN INCOMPLETA_____ PERFORACIN CAMERAL _____ PERFORACIN RADICULAR _____ ESPACIO DEL
LIGAMENTO PERIODONTAL ENSANCHADO _____ RAREFACCIN APICAL_____ RAREFACCIN LATERAL ____ CUERPO
EXTRAO INTRARRADICULAR _____ FRACTURA RADICULAR ______ REABSORCIN INT______ REABSORCION
EXT_____DISMINUCIN DEL LUMEN DEL CONDUCTO _____ OBTURACIN ENDODONTICA PARCIAL _____
SOBREOBTURACIN _____ OTRO IMPORTANTE ____________________________________

DIAGNSTICO, PRONSTICO, PLAN DE TRATAMIENTO

FECHA :___________

DIENTE:______________________________
DIAGNSTICO :___________________________________________________________________
PRONSTICO : ____________________________________________________________________
PLAN DE TRATAMIENTO : ____________________________________________________________
CONDUCTO
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CONDUCT. TENT.
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CONDUCT. DEF.
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PUNTO DE REF.
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DIAGNSTICO, PRONSTICO, PLAN DE TRATAMIENTO

L.A.P
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FECHA :___________

DIENTE:______________________________
DIAGNSTICO :___________________________________________________________________
PRONSTICO : ____________________________________________________________________
PLAN DE TRATAMIENTO: ____________________________________________________________
CONDUCTO
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CONDUCT. TENT.
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CONDUCT. DEF.
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PUNTO DE REF.
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L.A.P
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ANEXO HISTORIA CLNICA

ENDODONCIA
CONSULTA EXTERNA
UNIDAD DE SALUD ORAL

CIRUGIA ENDODONTICA:

Cdigo: CEX-FO-323-008

Versin: 3

FECHA:_____________ HORA:________

DIENTE:______________________________
DIAGNSTICO :_________________________________________________
PROCEDIMIENTO REALIZADO:
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PRONSTICO : ____________________________________________________________________
RECOMENDACIONES POSTRATAMIENTO :
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NOTAS DE EVOLUCIN
Fecha y Hora:
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CONTROLES :
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SE ENTREGA CONTRARFERENCIA AL PACIENTE: SI___ NO___

SE ENTREGAN RADIOGRAFAS AL PACIENTE:

SI___

NO___

FIRMA DEL PACIENTE QUE HACE CONSTAR HABERLOS RECIBIDO:__________________________

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