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HISTORIA CLÍNICA.pdf
- 1. HISTORIA CLÍNICA DATOS DE IDENTIFICACIÓN Nombre: ____________________________________________________ Edad: ______________________________________________________ Género: __________________ Estado civil: ________________________ Religión: ____________________________________________________ Domicilio: ___________________________________________________ Ocupación: __________________________________________________ Nivel socioeconómico: _________________________________________ Escolaridad: _________________________________________________ FAMILIOGRAMA / GENOGRAMA
- 2. MOTIVO DE LA CONSULTA __________________________________________________________________ __________________________________________________________________ NACIMIENTO Y DESARROLLO DE LA INFANCIA __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ DESARROLLO DE LA ADOLESCENCIA __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ DESARROLLO DE LA ADULTEZ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ DESARROLLO DE LA VEJEZ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________
- 3. HISTORIAL DE SALUD __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ HISTORIAL ESCOLAR __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ HISTORIAL LABORAL ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ HISTORIAL FAMILIAR ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ HISTORIAL SEXUAL __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________
- 4. CONTEXTO ACTUAL (CON QUIÉN VIVE, CÓMO, DÓNDE, ETC) __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ HÁBITOS (ALIMENTICIOS, SUEÑO, DROGAS) __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ ESTADO ACTUAL (QUÉ LE PASA, CÓMO SE ENCUENTRA, DESDE CUÁNDO, CÓMO EMPEZÓ) __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ ASPECTO FÍSICO __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ PSIQUE: ACTITUD, COMUNICACIÓN, FORMA DE VINCULARSE __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________
- 5. SÍNTOMAS DE DETERIORO PSÍQUICO a) Conciencia: (lúcido, confuso, comatoso, somnoliento, etc) __________________________________________________________________ b) Atención: (atento, ausente, distraído, preocupado, relajado, disperso, etc) __________________________________________________________________ c) Sensopercepción: (alucinaciones visuales, auditivas, gustativas, táctiles, etc) __________________________________________________________________ d) Orientación: (tiempo: día de la semana, mes, espacio, cuidado, lugar, etc) __________________________________________________________________ e) Memoria: ____________________________________________________ HISTORIAL DE LA PRIMERA EXPERIENCIA DE PÉRDIDA ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ HISTORIAL DE PÉRDIDAS SIGNIFICATIVAS ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________
- 6. HISTORIAL DE LA CRISIS MÁS SIGNIFICATIVA DE SU VIDA ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ OBSERVACIONES