pauta anotación pasos prácticos

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: ________________________________________________________________________