Assessment and evaluation of the physical or mental state of a patient, based on the information obtained from the interview, the patient's medical history and anamnesis, physical examinations, laboratory tests and the results of psychological tests. Its objective is to make a diagnosis and establish a treatment.
This record allows the development of the anamnesis of each patient, in which, in the first part, the doctor describes the main symptoms of the patient's disease, its onset and its progression. In the second part, the patient's history is collected: vaccinations, allergies, previous hospital admissions, medication taken, family history, exposure to stressful situations, consumption of toxic substances, etc.
