HISTORIA CLÍNICA

I. DATOS DE IDENTIFICACIÓN:

FECHA: ________________ HORA: _____________

NOMBRES Y APELLIDOS: _____________________________________________________________________________

EDAD: ___________ LUGAR Y FECHA DE NACIMIENTO: ____________________________________________________

ESTADO CIVIL: ______________________________

GRADO DE INSTRUCCIÓN: _________________________________________________

OCUPACIÓN: ___________________________________________________________

INCLINACIÓN DE FE O RELIGIÓN: ____________________________________________

N° DE HIJOS O HERMANOS: ________________________________________________

CON QUIEN VIVE: ___________________________________________________________________________________

DIRECCIÓN DE HABITACIÓN: __________________________________________________________________________

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TELEFONO LOCAL: ___________________________________ CELULAR: __________________________________

DIRECCIÓN DE UN FAMILIAR O AMIGO: _________________________________________________________________

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TELÉFONO LOCAL: ___________________________________ CELULAR: ___________________________________

II. MOTIVO DE CONSULTA: _______________________________________________________________________

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III. ENFERMEDAD ACTUAL:________________________________________________________________________

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IV. GENITOGRAMA:

V. ANTECEDENTES PERSONALES (MÉDICOS): _________________________________________________________

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VI. ANTECEDENTES FAMILIARES (MÉDICOS): _________________________________________________________

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VII. HÁBITOS PSICO-BIOLÓGICOS: ________________________________________________________________

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VIII. EXAMEN MENTAL:

A. DESCRIPCIÓN GENERAL DEL PACIENTE:

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B. FUNCIONES MENTALES SUPERIORES:

CONCIENCIA:
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ORIENTACIÓN:
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ATENCIÓN Y CONCENTRACIÓN:
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MEMORIA:
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NIVEL DE FUNCIONAMIENTO INTELECTUAL:

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PENSAMIENTO:
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LENGUAJE:
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AFECTIVIDAD:

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 PSICOMOTRICIDAD:
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SENSOPERCEPCIÓN:
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C. CONCIENCIA DE PROBLEMÁTICA:
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D. JUICIO DE EVALUACIÓN DE LA REALIDAD:

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