Historia Clínica.

Fecha: 29/10/2020 No. De Historia________________

Apellidos: Sánchez Martínez
Nombres: Pedro Antonio
Fecha de Nacimiento: 20/10/1992 Edad: 22 años Sexo: Masculino
Procedencia: Ensanche Ozama, Santo Domingo Este.
Teléfono: 809-960-2364
Residencia: Calle Ac/vo 20-30 No.15, Ensanche Ozama, Santo Domingo Este
Referido por: Acompañante: María Martínez (Madre)
Escolaridad: Estado Civil:
Religión: Católico Ocupación: Estudiante
Especialista:

Hallazgos de la Examinación (Motivos de Consulta)

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HISTORIA DE LA ENFERMEDAD ACTUAL

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ANTECEDENTES PERSONALES PATOLOGICOS

Niñez:
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Adolescencia: ________________________________________________________
Adultez: _____________________________________________________________
Hospitalarios: ________________________________________________________
Quirúrgicos__________________________________________________________
Transfucionales_______________________________________________________
Alérgicos:
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Medicamentos: _______________________________________________________
Traumáticos: _________________________________________________________
ESFERA PSICOSEXUAL
Inicio Vida Sexual ____________________
Relaciones Formales: __________________
Relaciones Informales: _________________
Relaciones Homosexuales: _______________

HABITOS TOXICOS
Café______________
Tabaco_____________
Alcohol_____________
Tizanas: _____________
Drogas Ilegales: _____________

ANTECEDENTES PSIQUIATRICO FAMILIARES

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CURVA VITAL
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EXAMEN MENTAL
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HALLAZGOS FISICOS
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PRUEBAS DE LABORATORIOS
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OTRAS OBSERVACIONES.
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FORMULACION DIAGNOSTICA.
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Tratamiento:
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