HISTORIA CLÍNICA

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I.-IDENTIFICACION

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Estado

RESIDENCIA ACTUAL: ____________________________________________________________________________________

Calle No.

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Colonia Estado Teléfono

ESTADO CIVIL: ______________________RELIGIÓN: _________________ ESCOLARIDAD: _______________________

OCUPACIÓN: _______________________________ SITUACIÓN ECONOMICA: ___________________________________

DIAGNÓSTICO: __________________________________________________________________________________________

II.- MOTIVO DE CONSULTA

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III.-HISTORIA DEL PADECIMIENTO ACTUAL

1.-Enfermedad actual:

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2.- Historia del desarrollo (concepción, parto, Infancia)

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3.- Antecedentes personales patológicos:

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4.-Antecedentes familiares

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5.-Familiograma

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6.-Historia escolar

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7.-Historia laboral

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8.-Historia sexual

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9.- Historia de Relaciones Interpersonales

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IV.-EXPLORACION PSICOPATOLOGICA

1.-Descripción general (aspecto, conducta explícita, actividad psicomotora y actitud)

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2- Humor y afectividad (humor, afecto)

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3.- Características del lenguaje

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4.- Percepción

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5.-Contenido del pensamiento (proceso, contenido y control del pensamiento)

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6.- Sensorio y cognición (conciencia, orientación y memoria, concentración y atención, lectura y

escritura, capacidad visoespacial, pensamiento abstracto y información e inteligencia)

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7.- Impulsividad

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8.- Juicio e introspección

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V.-PRUEBAS COMPLEMENTARIAS

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VI- IMPRESIÓN DIAGNÓSTICA:(Acorde al CIE 10)

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VII- PRONÓSTICO

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VIII- TRATAMIENTO

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Nombre y Firma