This document contains a multimodal clinical history form for adults. It collects information about the patient's name, age, profession, address, phone number, date, chief complaint, triggering factors for the current episode, family history, social and family support systems, and observations. It also includes sections to summarize the patient's cognitive, affective, somatic, and interpersonal areas, and provides space for a diagnosis.

1. HISTORIA CLINICA MULTIMODAL DE ADULTOS
Nombre:_________________________________________
Edad: _____________
Profesión:________________________
Estado civil:_______________________
Domicilio____________________________________________
Teléfono:_________________________
Fecha: _____________
1. MOTIVO DE CONSULTA:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
2. FACTORES DESENCADENANTES DEL EPISODIO ACTUAL:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
3. ANTECEDENTES FAMILIARES:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
4. VALORACIONDEL SOPORTE SOCIO-FAMILIARES:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
5. OTRAS OBSERVACIONES:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

2. 6. RESUMEN MULTIMODAL DE AREAS IMPLICADAS:
 Áreacognitiva
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Áreaafectiva
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Áreasomática
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Área interpersonal
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
7. DIAGNOSTICO
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________