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PAUTA ANOTACIN PASOS PRCTICOSHISTORIA CLNICAIdentificacinNombre:Edad:Fecha de nacimiento:Escolaridad: Ocupacin:Antecedentes Familiares____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Antecedentes socialesPersonalidad premrbida________________________________________________________________________________________________________________________________________________Relaciones sociales__________________________________________________________________________________________________________________________________________Historia Psicosexual__________________________________________________________________________________________________________________________________________Antecedentes Mrbidos-Mdicos: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________-Quirrgicos: __________________________________________________________________-Traumatismos: ________________________________________________________________-Psiquitricos: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________Embarazo: ____________________________________________________________________Motivo de consulta:__________________________________________________________________________________________________________________________________________Enfermedad Actual: _________________________________________________________________________________________________________________________________________HbitosEdad de inicioConsumo promedio
Tabaco
Alcohol
Marihuana
Pasta Base
Cocana
Solventes
EXAMEN MENTALApariencia:_________________________________________________________________________________________________________________________________________________Conducta:_____________________________________________________________________Orientacin:___________________________________________________________________Comprensin:__________________________________________________________________Concentracin:_________________________________________________________________Pensamiento:_______________________________________________________________________________________________________________________________________________Conciencia:_________________________________________________________________________________________________________________________________________________Juicio de realidad:___________________________________________________________________________________________________________________________________________Lenguaje:__________________________________________________________________________________________________________________________________________________Afectividad:________________________________________________________________________________________________________________________________________________Senso-percepcin:___________________________________________________________________________________________________________________________________________Memoria:_____________________________________________________________________Inteligencia:___________________________________________________________________DiagnsticoEje1:_________________________________________________________________________Eje 2: ________________________________________________________________________Eje3: _________________________________________________________________________Eje 4: ________________________________________________________________________Eje 5: ________________________________________________________________________
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