HISTORIA CLNICA

Fecha: ________________________

1) FICHA DE IDENTIFICACIN
1.-Nombre:
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2.-Edad: (en aos cumplidos) ________________
3.-Sexo: (1) Masculino (2) Femenino ________________
4.-Escolaridad (No. de aos terminados): ________________
5.-Estado Civil: (Marque slo una opcin):
(1) ___ Casado (a) (2) __ Soltero (a)
(3) ___ Separado (a) (4) __ Divorciado (a)
(5) ___ Unin Libre (6) __ Viudo (a)

6.-Fecha y lugar de Nacimiento:

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7.-Ocupacin actual:
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8.-Religin: ___________________________________________
9.-Con quien vive actualmente (Marque las opciones necesarias):
(1) __ Esposo (a) (2) __ Nios
(3) __ Padres (4) __ Hermanos
(5) __ Amigos (6) __ Parientes
(7) __ Solo (8) __ Otros

10.-Domicilio:
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11.-Telfono fijo: _______________________ Telfono celular:
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2) EXAMEN MENTAL

Descripcin de la apariencia fsica:

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Actitud frente a la entrevista:

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Otras observaciones:
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3) HISTORIA DEL DESARROLLO

1.- Concepcin, embarazo y nacimiento:

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2.- Alimentacin y sueo:

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3.- Lenguaje y motricidad:
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10.- Desarrollo de la personalidad:

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11.- Patrones de juego:

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1.- Disciplina:
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13.- Esfera familiar:

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14.- Esfera Social:

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4) DATOS CLNICOS

1.- Motivo de consulta, severidad del problema y tratamientos anteriores:

La razn por la cual asiste a consulta es:
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2.- Salud durate la infancia (cirugas, vacunas, enfermedades, accidentes,

revisiones
mdicas):
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3.- Conductas en la infancia (chuparse el dedo, mojar la cama,

tartamudeo, terrores nocturnos, morderse las uas, sonambulismo):
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4.- Informacin referente a su sexualidad:

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5.- Historia menstrual (si aplica):

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6.- Antecedentes de enfermedades hereditarias:

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5) DATOS DE PERSONALIDAD

1.- Miedos:
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2.- Intereses, pasatiempos y actividades:

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3.- Historia-habilidades escolares y hbitos:

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4.- Socializacin y conducta:

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5.- rea Marital:
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6.- rea laboral:

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7.- Emociones y sentimientos:

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8.- Auto-descripcin:
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9.- Sensaciones agradables y desagradables:

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10.- Padecimientos o problemas actuales (fsicos y

emocionales):___________________
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11.- Situacin actual:

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6) GENOGRAMA

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DIAGNSTICO

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1.- Impresin diagnstica:
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2: Plan a sugerir:
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Diagnstico elaborado por:

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Psic.

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