HISTORIA CLINICA ESTUDIANTE

BIENESTAR UNIVERSITARIO[pic 1][pic 2]

DEPARTAMENTO DE PSICOLOGÍA

HISTORIA CLINICA ESTUDIANTE               

Psicólogo  __________________Enfoque ___________________Área ___________________

Dirección ___________________ Teléfonos _________________ Ciudad _________________

Institución   _______________________________________ Fecha _________________________

1. DATOS PERSONALES

Nombre _____________________________________  Sexo ___________________________

Fecha y lugar de nacimiento ________________________________      Estado civil __________

Nivel educativo ______________ Profesión ________________ Ocupación    _______________

Religión ________    Hijo(s) _____   Lugar de residencia ___________          Estrato ___________

Dirección _______________________Barrio _______________ Teléfonos ________________

Eps ______________  Email _____________________________ 

DATOS CONTACTO

Nombre _______________________________________________________________________

Lugar de residencia ___________________ Dirección_ _________________________________

Teléfonos __________________ Parentesco ________________ ________________________

OBSERVACIONES

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1. MOTIVOS  DE CONSULTA

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1. SINTOMATOLOGIA ASOCIADA

Emocional

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Mental

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Físico

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Sentido

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RELATO  PSICOGENOSOCIOGRAMA

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ORDEN EMOCIONAL

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AREA PERSONAL

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¿En qué áreas o vivencias de tu vida no eres feliz?

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ANALISIS DE PAREJA

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