You are on page 1of 1

INSTITUTO PBLICO MUNICIPAL DE LA SALUD

DEPARTAMENTO DE PSICOLOGA
INFORME PSICOLGICO

DATOS DE IDENTIFICACIN
NOMBRES Y APELLIDOS: _____________________________________________SEXO: _________
FECHA DE NACIMIENTO: __________________EDAD: _______NIVEL EDUCATIVO: ____________
NOMBRE DEL REPRESENTANTE: _____________________________________EDAD: ___________
FECHA: _______________________________________
MOTIVO DE CONSULTA:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
DIAGNOSTICO:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

Mara Alejandra Andrade Bracho


Psiclogo

You might also like