HISTORICA CLNICA

HISTORIA Nro:
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FECHA:

I-DATOS DEMOFRAFICOS:
NOMBRE:

C.I:

EDAD: _____ FECHA DE NACIMIENTO:

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Lugar:

Sexo: MASC (__) FEM (__)

Nro.Hijos: (_____)

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Edo. CIVIL: S (__) C (__) V (__) D (__) Conc (__)

Direccin de residencia:
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Profesin:

Ocupacin:

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Lugar de trabajo:
Acompaante:
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Parentesco:

Nro de contacto:____________________________
II- MOTIVO DE CONSULTA:
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III-ENFERMEDAD ACTUAL:
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IV-ESTRESORES PSICOSOCIALES ACTUALES:

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V-ANTECEDENTES: (mdicos, quirrgicos, hospitalizacin)

Familiares:

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Personales:

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VI-ANTECEDENTES PSIQUITRICOS:
Familiares:

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Personales:

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VII-HBITOS: (habito, frecuencia, dosis, duracin):

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VIII-GENITOGRAMA, BIOPATOGRAFA:

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X-RESUMEN DE DATOS POSITIVOS:

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XI-IMPRESIN DIAGNOSTICA SINDROMATICA:

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XII-DIAGNOSTICO:
A).CIE-10:
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B).DSM-IV:
EJE
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I:

EJE

II:

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EJE

III:

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EJE

IV:

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EJE V: ________________________________________________________________

Puntos en la

escala GAF.

IX-EXAMEN MENTAL:
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Presentacin
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Actitud
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Nivel de
consciencia:
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Edo.
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Cognoscitivo:
Atencin
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Concentracin
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Orientacin
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Memoria
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Juicio prctico
Inteligencia
Lenguaje:
Tono
Volumen
Ritmo
Fluidez
Pensamiento:
Curso
Contenido
Afectividad:
Eutimia
Hipertimia
Distimia
Humor
Emocin
Sentimiento
Sensopercepcin
:
Ilusiones
Alucinaciones
Psicomotricidad:
Vida instintiva:
Signos vitales
Alimentacin
Sueo
Sexualidad
Juicio de la
realidad: