Historia Clínica del Desarrollo

I- IDENTIFICACIÓN

Nombre completo: ________________________________________________________________

Fecha de nacimiento: ______________________________________________________________

Edad Cronológica: _______________ Sexo: _____________ Identidad de género: ______________

Nivel Educacional: _________________________________________________________________

Establecimiento Educacional (si lo hay) _________________________________________________

Ocupación(laboral):____________________________Lugar: _______________________________

Cantidad de horas de trabajo: ______________________ Cantidad de horas libres: ____________

II- ANTECEDENTES FAMILIARES:

Personas con las que convive (señalar vínculo y cantidad)

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Calidad de las relaciones familiares en la Actualidad:

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Estado Civil: _______________________________

Antecedentes mórbidos Familiares:

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Antecedentes mórbidos familiares de salud mental:

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Historia Escolar:
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Hábitos de lectura:
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Hábitos de recreación:
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Cantidad de horas de sueño: _________________________

Cantidad de horas de pantalla: ________________________

Calidad del sueño: _________________________________

Enfermedades Importantes:
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Medicamentos de consumo crónico:

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Consumo de Drogas o Alcohol: (indicar tipo de sustancia y frecuencia de consumo)

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Motivo por el que consulta:

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Expectativas del proceso de evaluación:

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Calidad de las relaciones sociales:

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Calidad de las relaciones escolares/familiares:

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Calidad del lenguaje durante la entrevista:

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Observaciones Adicionales:
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Fecha de la entrevista: ________________________

Nombre del entrevistador: ________________________________ firma: ___________________

Nombre del entrevistado: _________________________________ firma: ___________________