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HISTORIA CLNICA PSICOLGICA

HOSPITALIZACIN
UNIDAD DE SALUD MENTAL

Cdigo: HSP-FO314-001

Versin: 0

Fecha: _______ Servicio: __________ Historia Clnica N: _____________


I.

DATOS DE IDENTIFICACIN

Nombre completo: _______________________________________________


Edad: ____ Sexo: ____ Estado Civil: ____ Natural de: ________________
Procedencia: _________________ Ocupacin: _______________________
Escolaridad: __________ Religin: ____________
N Documento Identificacin:_________________________
PROBLEMATICA ACTUAL (episodio actual; antecedentes de enfermedad mental, tratamientos
previos).

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ANTECEDENTES PERSONALES (Estado somtico actual y pasado; hbitos de salud y dieta;
tratamientos mdico y psicolgicos anteriores; historia escolar y laboral)

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EXPERIENCIAS TRAUMTICAS
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ANTECEDENTES FAMILIARES (Composicin familiar; antecedentes de importancia; redes de
apoyo familiar, social quines y Dinmica Familiar-.).

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HISTORIA CLNICA PSICOLGICA

HOSPITALIZACIN
UNIDAD DE SALUD MENTAL

Cdigo: HSP-FO314-001

Versin: 0

FAMILIOGRAMA

EXAMEN MENTAL (Orientacin, Porte y actitud, Afecto, lenguaje, Pensamiento, Cognicin,


Introspeccin, Prospeccin)
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DIAGNSTICO
CIE-10 : ____________________________ Cdigo: ___________
DSM IV
Eje I ___________________________________________________
Eje II ___________________________________________________
Eje III __________________________________________________
Eje IV __________________________________________________
Eje V __________________________________________________
ANALISIS
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Firma y Sello ______________________________________________
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