LA UNIVERSIDAD DEL ZULIA

FACULTAD DE MEDICINA
ESCUELA DE MEDICINA
DEPARTAMENTO DE CIENCIAS DE LA CONDUCTA
CTEDRA DE PSICOLOGIA MDICA
HISTORIA CLNICA

Fecha:

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Realizada por Br.: ________________________________________________________
Nombres y Apellidos:

Edad:

C.I.:________________________
Sexo:
M

Lugar y Fecha de Nacimiento:

Estado Civil:

Raza:

Religin:

S C D V U
Grado de Instruccin:

Profesin u Ocupacin:

Ocupacin actual:

Empleo:
Si

Domicilio Habitual:

Telfonos:

Informacin aportada por:

Parentesco:

No

Confiabilidad:
Si Poco

MOTIVO DE CONSULTA:
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ENFERMEDAD ACTUAL:
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EXAMEN FISICO:
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EXAMEN MENTAL:

Historia Clnica
I.

Apariencia General y Conducta:

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II. Nivel Cognitivo:
Conciencia: ________________________________________

Orientacin: ___________________________________________

Atencin: __________________________________________

Concentracin: ________________________________________

Memoria: _____________________________________________________________________________________________________
Ideacin: _____________________________________________________________________________________________________
Juicio: ____________________________________________________________________________________________________
Razonamiento: ____________________________________________________________________________________________
Imaginacin: ______________________________________________________________________________________________
Pensamiento: ______________________________________________________________________________________________
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Lenguaje: _________________________________________________________________________________________________
Inteligencia: __________________________________________________________________________________________________
Insight: ____________________________________________________________________________________________________
III. Nivel Senso-perceptivo:
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V.

Nivel Psicomotriz:

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V. Nivel Afectivo:
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VI.

Nivel Fisiolgico (Sueo, Apetito, Sexualidad):

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ANTECENDENTES PERSONALES (Fsicos y Mentales):
Pre, peri y postnatal:

Historia Clnica
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Niez:
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Escolaridad:
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Adolescencia:
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Adultez:
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Vejez:
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Hbitos:
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Personalidad:
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Historia Mdica:
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Historia Clnica
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Historia laboral:
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Situacin de vida actual y familiar:
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ANTECEDENTES FAMILIARES (Fsicos y Mentales):
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ENTREVISTA CON FAMILIARES:
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DIAGNSTICO PRESUNTIVO:
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Entrevista

realizada

por

________________________________

Br.:

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Firma: