Historia clínica

Filiación

Nombre: _____________________________________________________________________

Sexo: ________________________________________________________________________

Edad: ________________________________________________________________________

F. Nacimiento: _________________________________________________________________

L. Nacimiento: _________________________________________________________________

Estado civil: ___________________________________________________________________

G. instrucción: _________________________________________________________________

Ocupación: ___________________________________________________________________

Religión: ______________________________________________________________________

Lugar de procedencia: ___________________________________________________________

Fecha de ingreso al hospital: ______________________________________________________

Fecha de ingreso a hospitalización: ________________________________________________

Tipo de rh _______________________________________

Informante: __________________________________________________________________

ANAMNESIS

Tiempo de enfermedad: _________________________________________________________

Episodio actual: ________________________________________________________________

Inicia: _______________________________________________________________________

Curso: _______________________________________________________________________

Signos y síntomas: ______________________________________________________________

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Relato de enfermedad (Episodio):

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Examen Mental

Porte comportamiento y actitud:

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Conciencia:

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Atención:

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Orientación:

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Lenguaje:
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Estado afectivo:
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Pensamiento:
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Percepción:
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Memoria:

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Acción:

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Inteligencia:

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Sueño:

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Conciencia de Enfermedad:
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Impresión Diagnostica:
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Plan de Trabajo:

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Fundamento teórico:

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Responsable (S):