PAUTA ANOTACIN PASOS PRCTICOS

HISTORIA CLNICA
Identificacin
Nombre

Edad

Fecha de nacimiento

Escolaridad

Ocupacin

:
Antecedentes Familiares

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Antecedentes sociales
Personalidad
premrbida_________________________________________________________________
__
_____________________________________________________________________________
Relaciones
sociales_____________________________________________________________
_____________________________________________________________________________
Historia
Psicosexual_____________________________________________________________
_____________________________________________________________________________
Antecedentes Mrbidos
-Mdicos:
_____________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
-Quirrgicos:
__________________________________________________________________

-Traumatismos:
________________________________________________________________
-Psiquitricos:
_________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Embarazo:
____________________________________________________________________
Motivo de
consulta:_____________________________________________________________
_____________________________________________________________________________
Enfermedad Actual:
____________________________________________________________
_____________________________________________________________________________
Hbitos
Edad de inicio
Tabaco

Alcohol

Marihuan
a

Pasta
Base

Cocana

Consumo promedio

Solventes

EXAMEN MENTAL
Apariencia:__________________________________________________________________
__
_____________________________________________________________________________
Conducta:___________________________________________________________________
__
Orientacin:_________________________________________________________________
__
Comprensin:_______________________________________________________________
___
Concentracin:______________________________________________________________
___
Pensamiento:_______________________________________________________________
___
_____________________________________________________________________________
Conciencia:_________________________________________________________________
___
_____________________________________________________________________________
Juicio de
realidad:______________________________________________________________
_____________________________________________________________________________
Lenguaje:___________________________________________________________________
__
_____________________________________________________________________________
Afectividad:_________________________________________________________________
__
_____________________________________________________________________________
Sensopercepcin:______________________________________________________________

_____________________________________________________________________________
Memoria:___________________________________________________________________
__
Inteligencia:_________________________________________________________________
__
Diagnstico
Eje1:________________________________________________________________________
_
Eje 2:
________________________________________________________________________
Eje3:
_________________________________________________________________________
Eje 4:
________________________________________________________________________
Eje 5:
________________________________________________________________________