HISTORIA CLINICA NEUROPSICOLOGICA ADULTOS

1. DATOS DEMOGRAFICOS
1.1. NOMBRE:_________________________________________________________________
1.2. DOCUMENTO DE IDENTIDAD:__________________________________________________
1.3. EDAD:___________________________________________________________________
1.4. NIVEL DE ESCOLARIDAD:_____________________________________________________
1.5. OCUPACION ACTUAL:_______________________________________________________
1.6. OCUPACION ANTERIOR:_____________________________________________________
1.7. LATERALIDAD:_____________________________________________________________
1.8. TELEFONO:_______________________________________________________________
1.9. DIRRECCION:______________________________________________________________
2. MOTIVO DE CONSULTA:
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3. QUIEN REMITE:
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4. HISTORIA CLINICA
4.1.1. HISTORIA PERSONAL:
ALTERACIONES DE NEURODESARROLLO IMPORTANTES:___________________________
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DIAGNOSTICOS PREVIOS:_________________________________________________
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4.1.2. HISTORIA ESCOLAR
RENDIMIENTO ACADEMICO: _____________________________________________
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PRESENT REPITENCIA ESCOLAR: __________________________________________
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OBSERVACIONES ADICIONALES: ___________________________________________
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4.1.3.HISTORIA LABORAL
CARGOS OCUPADOS RECIENTEMENTE Y POR CUANTO TIEMPO : ___________________
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EXPOSICION A SUSTANCIAS TOXICAS:_______________________________________
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REALIZACION DE TURNOS NOCTURNOS:_____________________________________
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5. ANTECEDENTES MEDICOS
5.1.1.ENFERMEDADES PREVIAS: ( NEUROLOGICAS, PSIQUIATRICAS, TOXICOLOGICAS O
SISTEMICAS) _________ _________________________________________________
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5.1.2.MANEJO FARMACOLOGICO: ______________________________________________
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5.1.3.ANTECEDENTES QUIRURGICOS: __________________________________________
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6. EVOLUCION DE LA ENFERMEDAD
6.1.1.TIEMPO DE EVOLUCION : _________________________________________________
6.1.2.INICIO O PRIMEROS SINTOMAS: ___________________________________________
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6.1.3.MANEJO PREVIO : _____________________________________________________
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6.1.4.ESTADO ACTUAL: _______________________________________________________
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7. PROCESOS COGNOSCITIVOS:
7.1.
ORIENTACION:
TIEMPO:___________________________________________________________
ESPACIO:___________________________________________________________
PERSONA:__________________________________________________________
7.2.
ATENCIN:
DIFICULTADES PARA CONCENTRARSE:_______________________________________
7.3.
MEMORIA.
ANTEROGRADA: RECORDAR ALGN EPISODIO QUE LE HAYA OCURRIDO EN LA VIDA
COTIDIANA.:_____________________________________________________________
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RETROGRADA: MEMORIA DE ACONTECIMIENTOS PBLICOS O EXPERIENCIAS
PERSONALES DEL PASADO:_________________________________________________
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SEMNTICA:
VOCABULARIO,
NOMBRES
Y
CONOCIMIENTOS
GENERALES.:________________________________________________________
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7.4.

LENGUAJE.
PALABRAS ADECUADAS, GRAMTICA, ERRORES DE PALABRAS (PARAFASIAS):________
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COMPRENSIN DE LAS PALABRAS Y GRAMTICA.:_____________________________
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LECTURA.:___________________________________________________________
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ESCRITURA: EXPLORAR ORTOGRAFA Y EL COMPONENTE MOTOR.:________________

7.5 CAPACIDAD NUMRICA.

CONTAR MONEDAS, COMPRAR, FACTURAS(FINANZAS EN GENERAL):______________
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7.6 CAPACIDAD VISUOESPACIAL.
VESTIRSE.:___________________________________________________________
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CAPACIDAD CONSTRUCCIONAL.:_________________________________________
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ORIENTACIN ESPACIAL:_______________________________________________
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7.7. FENMENO DE NEGLIGENCIA EXTRAPERSONAL.

NEGLIGENCIA DEL ESPACIO.:__________________________________________________
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NEGLIGENCIA DEL CUERPO O PARTE CORPORAL:________________________________
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7.8. PERCEPCIN VISUAL.
RECONOCIMIENTO E IDENTIFICACIN DE LAS PERSONAS.:___________________________
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IDENTIFICACIN DE OBJETOS, LETRAS Y NMEROS.________________________________
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7.9. OTROS:
ALUCINACIONES: VISUALES, AUDITIVAS, TCTILES, OLFATORIAS.____________________
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CAMBIOS DE PERSONALIDAD Y CONDUCTA SOCIAL INCLUIDOS HBITOS ALIMENTARIOS Y
SEXUALES.:______________________________________________________________
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RACIOCINIO Y CAPACIDAD DE RESOLVER PROBLEMAS.:______________________________
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DEPRESIN: CONDUCTA, ENERGA, CONCENTRACIN, ANIMO, DATOS BIOLGICOS
(APETITO, SUEO).________________________________________________________
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HIPOTESIS DIAGNOSTICA:
DIAGNOSTICO DIFERENCIAL: ______________________________________________________
DIAGNOSTICO ETIOLOGICO: _______________________________________________________
DIAGNOSTICO TOPOGRAFICO: ______________________________________________________
DIAGNOSTICO SINDROMATICO: ____________________________________________________

PERSONA QUE ELABORO LA HISTORIA