CASO CLINICO

ANAMNESIS
I. DATOS GENERALES

 Apellidos y Nombres : __________________________________

 Edad : _________________________________
 Sexo : _________________________________
 Fecha de Nacimiento : _________________________________
 Lugar de Nacimiento : _________________________________
 Procedencia : _________________________________
 Grado de Instrucción : _________________________________
 Ocupación : _________________________________
 Informante : _________________________________
 Lugar de Evaluación : _________________________________
 Fecha de Evaluación : _________________________________
 Examinador : _________________________________

II. MOTIVO DE CONSULTA

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III. HISTORIA DE LA ENFERMEDAD ACTUAL

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IV. ANTECEDENTES PERSONALES.

a) Etapa prenatal
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b) Etapa natal:
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c) Etapa Post-Natal:
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Desarrollo psicomotor:

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c) Etapa escolar
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Desarrollo y función sexual
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d) Actividad laboral
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Hábitos e influencia nocivas o toxicas
Sueño:
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Alimentación:
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Alcohol y otros
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Religión:
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e) Enfermedades y accidentes:
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f) Personalidad:
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V. ANTECEDENTES FAMILIARES.
a) Composición Familiar
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b) dinámica Familiar

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c) Situación socioeconómica y ocupacional:

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VI. RESUMEN
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