Psicología

HISTORIA CLÍNICA

1.-DATOS IDENTIFICACIÓN:

Nombres: ________________________________________________________________

Apellido:_________________________________________________________________

Paterno Materno

Lugar y fecha de nacimiento

Provincia__________________ Ciudad ___________ día_____ mes ______ año_____

Edad Sexo Estado civil Instrucción Ocupación

M ( ) F ( ) S ( ) C ( ) D( ) UL ( )

Fecha: Investigador Remitido por

Día ……….. Mes …….. año …..

II. MOTIVO DE CONSULTA:

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III. HISTORIA DE LA ENEFERMEDAD:

Inicio ( signos y síntomas)

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Posibles causas:

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IV. HISTORIA PERSONAL:

1. Concepción, embarazo, parto, nacimiento:

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2. desarrollo psicomotor:

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3. Estudios y rendimiento:

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4. Enfermedades:

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5. Desarrollo y experiencias sexuales:

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6. Problemas emocionales:

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7. Aspectos de trabajo y relaciones interpersonales:

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V. HISTORIA FAMILIAR:

1. Tipo de hogar

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2. Estructura familiar:

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3. Situación económica y cultural:

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4. Relaciones familiares:

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5. Tipo de distracciones:

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6. Antecedentes patológicos:

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VI. ANÁLISIS DE FUNCIONES:

Intelectivas:

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Conciencia:

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Atención:

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Memoria:

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Sensopercepciones:

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Inteligencia:

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Pensamiento:

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AFECTIVAS:

Estado de ánimo:

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VOLITIVAS

Abulia:

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Hipoabulia:

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Actos impulsivos:

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Actos compulsivos:

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VII. EXAMENES COMPLEMENTARIOS:

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VII. DIAGNÓSTICO

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