• Author / Uploaded
• Jacinto Ozuna Franco

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Servicio de salud mental Historia Clínica Fecha:______________________ Apellidos:__________________________________

No. de Historia:_______ Nombres:_______________________________

Fecha de nacimiento:__/__/___ Edad:___ Sexo: M( ) F( ) Provincia:_____________________________ Residencia:_____________________________________________ Teléfono Residencial:______________ Cel.:______________ Referido por:________________________ acompañante:_____________________ MOTIVOS DE CONSULTA _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ HISTORIA DE LA ENFERMEDAD ACTUAL _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ ANTECEDENTES PSIQUIÁTRICOS _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________

ANTECEDENTES PERSONALES PATOLÓGICOS Niñez:__________________________________________________________________________________ Adolescencia:____________________________________________________________________________ Adultez:________________________________________________________________________________ Hospitalarios:____________________________________________________________________________ Quirúrgicos:_____________________________________________________________________________ Transfusionales:__________________________________________________________________________ Alérgicos:_______________________________________________________________________________ Medicamentosos:_________________________________________________________________________ Tratamientos:____________________________________________________________________________ ESFERA PSICO-SEXUAL Inicio vida sexual:_____________

Numero de conyugues:___

Relaciones informales:_____________

Relaciones formales:_____________

Relaciones homosexuales:

_____________

HÁBITOS TÓXICOS Café:_____________ Tabaco:_____________ Alcohol:_____________ Tizanas:_____________ Drogas ilegales:_____________ ANTECEDENTES PSIQUIÁTRICOS FAMILIARES _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ CURVA VITAL _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________

EXAMEN MENTAL _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ PRUEBAS DE LABORATORIOS _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ FORMULACIÓN DIAGNOSTICA _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ TRATAMIENTO _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________