This document contains sections for collecting a patient's personal and family medical history. It includes areas to document their name, age, gender, occupation, motivation for the consultation, childhood and adolescent development, adult and elderly development, health, school, work, family, and sexual histories. Current context, habits, physical and mental state, and histories of loss and crisis are also addressed. The purpose is to comprehensively understand the patient's background and current presentation.

1. HISTORIA CLÍNICA
DATOS DE IDENTIFICACIÓN
Nombre: ____________________________________________________
Edad: ______________________________________________________
Género: __________________ Estado civil: ________________________
Religión: ____________________________________________________
Domicilio: ___________________________________________________
Ocupación: __________________________________________________
Nivel socioeconómico: _________________________________________
Escolaridad: _________________________________________________
FAMILIOGRAMA / GENOGRAMA

2. MOTIVO DE LA CONSULTA
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NACIMIENTO Y DESARROLLO DE LA INFANCIA
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DESARROLLO DE LA ADOLESCENCIA
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DESARROLLO DE LA ADULTEZ
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DESARROLLO DE LA VEJEZ
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3. HISTORIAL DE SALUD
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HISTORIAL ESCOLAR
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HISTORIAL LABORAL
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HISTORIAL FAMILIAR
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HISTORIAL SEXUAL
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4. CONTEXTO ACTUAL (CON QUIÉN VIVE, CÓMO, DÓNDE, ETC)
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HÁBITOS (ALIMENTICIOS, SUEÑO, DROGAS)
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ESTADO ACTUAL (QUÉ LE PASA, CÓMO SE ENCUENTRA, DESDE
CUÁNDO, CÓMO EMPEZÓ)
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ASPECTO FÍSICO
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PSIQUE: ACTITUD, COMUNICACIÓN, FORMA DE VINCULARSE
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5. SÍNTOMAS DE DETERIORO PSÍQUICO
a) Conciencia: (lúcido, confuso, comatoso, somnoliento, etc)
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b) Atención: (atento, ausente, distraído, preocupado, relajado, disperso,
etc)
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c) Sensopercepción: (alucinaciones visuales, auditivas, gustativas,
táctiles, etc)
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d) Orientación: (tiempo: día de la semana, mes, espacio, cuidado, lugar,
etc)
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e) Memoria: ____________________________________________________
HISTORIAL DE LA PRIMERA EXPERIENCIA DE PÉRDIDA
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HISTORIAL DE PÉRDIDAS SIGNIFICATIVAS
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6. HISTORIAL DE LA CRISIS MÁS SIGNIFICATIVA DE SU VIDA
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OBSERVACIONES