HISTORIA CLÍNICA PSICOLÓGICA.

ANAMNESIS
I.

Datos de Filiación:
• Nom. y Apell._____________________________________________________________________:
• Sexo
: ____________ Edad :___________ Fecha de Nac.___________________:
• Lugar de Nac._________________________________:
Procedencia_______:
• Dirección
: ______________________________________ Télf:________________________
• Grado de Inst.________________________________:
Religión_______________:
• Estado Civil : ______________________________ Ocupación_________________________:
• Padre
: __________________________________________ Edad:____________________
• Madre
: __________________________________________ Edad:____________________
• Referente
: ______________________________________________________________________
• Informantes : ______________________________________________________________________
• Lugar de Eval.____________________________________________________________________:
• Fechas de Eval.___________________________________________________________________:
• Examinador : Psicólogo Jorge Luis Fernández Salguero.

II. Motivo de Consulta:
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III. Historia de la Enfermedad o del problema actual:
A. Tiempo:
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B. Forma de Inicio:
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C. Síntomas Principales:
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D.Relato:
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Antecedentes Clínicos: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ IV.____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ E. Etapa Post-Natal:  Primer Año: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________  Desarrollo Neuro-Psicomotor: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ . Etapa Pre-natal: “Embarazo o gestación” ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ B. Antecedentes Personales: A. Etapa Natal: “Parto” ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ C.

Rasgos Neuropáticos: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ E. Desarrollo y Función Sexual:  Aspectos Fisiológicos: (Sexo masculino. Religión: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ J. Etapa Escolar: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ F. Historia de la Recreación y de la vida: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ L. Sexo Femenino): __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________  Aspecto psicosexual y Matrimonio: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ G. Enfermedades y accidentes: ____________________________________________________________________________________ .Actividad Laboral: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ H.Servicio Militar: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ I. Hábitos e influencias nocivas o tóxicas: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ K.D.

ocupación): ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ D. Dinámica Familiar (Hábitos.____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ M. Composición Familiar: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ B. costumbres): ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ C. Condición Socioeconómica (vivienda. Personalidad Premórbida: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ V.Antecedentes Patológicos: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ VI. ubicación sociocultural. Antecedentes Familiares: A. Resumen: _______________________________________________________________________________________ . condiciones sanitarias.

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y Apell. persona y personas)._____________________________________________________________________: • Sexo : ____________ Edad :___________ Fecha de Nac. tono.___________________: • Lugar de Nac. Conciencia y Orientación: Atención y Concentración: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Conciencia o Estado de Alerta: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Orientación: (Tiempo. Lenguaje: (Ritmo. Actitud Porte y Comportamiento: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ III._______________________________: Religión_______________: • Estado Civil : ______________________________ Ocupación_________________________: • Padre : __________________________________________ Edad:____________________ • Madre : __________________________________________ Edad:____________________ • Referente : ______________________________________________________________________ • Informantes : ______________________________________________________________________ • Lugar de Eval. Atención.___________________________________________________________________: • Examinador : Psicólogo Jorge Luis Fernández Salguero. Datos de Filiación: • Nom. contenido) _______________________________________________________________________________________ . espacio.____________________________________________________________________: • Fechas de Eval.EXÁMEN PSICOLÓGICO O MENTAL I.________________________________: Procedencia_______: • Dirección : ______________________________________ Télf:________________________ • Grado de Inst. lugar. ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ IV. II.

Estado de Ánimo y Afectos: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ X. Pensamiento: (Curso y contenido) _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ VI. Funcionamiento Intelectual: Conocimientos Generales. Comprensión y Grado de Incapacidad del Problema o Enfermedad: _______________________________________________________________________________________ . ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Memoria._______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ V.Memoria: (Corto y largo plazo) _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ VIII. Percepción: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ VII. ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Pensamiento: Razonamiento y Juicios ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ IX.

Resumen: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ ._______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ XI.

Interpretación de los instrumentos: _______________________________________________________________________________________ . Datos de Filiación: • Nom. Instrumentos Utilizados: ψ ψ ψ ψ ψ ψ ψ IV. y Apell. II. I._________________________________: Procedencia_______: • Dirección : ______________________________________ Télf:________________________ • Grado de Inst._____________________________________________________________________: • Sexo : ____________ Edad :___________ Fecha de Nac.___________________: • Lugar de Nac. Observaciones Generales: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ III.________________________________: Religión_______________: • Estado Civil : ______________________________ Ocupación_________________________: • Padre : __________________________________________ Edad:____________________ • Madre : __________________________________________ Edad:____________________ • Referente : ______________________________________________________________________ • Informantes : ______________________________________________________________________ • Lugar de Eval.___________________________________________________________________: • Examinador : Psicólogo Jorge Luis Fernández Salguero.INFORME PSICOMÉTRICO.____________________________________________________________________: • Fechas de Eval.

Resumen: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _____________________________ Fernández Salguero Jorge Luis Psicólogo ._______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ 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_______________________________________________________________________________________ _______________________________________________________________________________________ V.

ψ Entrevista.___________________: • Lugar de Nac. ψ Historia Clínica. Motivo de Consulta: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ III.____________________________________________________________________: • Fechas de Eval.INFORME PSICOLÓGICO I.___________________________________________________________________: • Examinador : Psicólogo Jorge Luis Fernández Salguero. Técnicas e instrumentos Utilizados: ψ Observación. ψ Pruebas Psicométricas _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ IV. II. Antecedentes Personales y Familiares: _______________________________________________________________________________________ . y Apell.________________________________: Religión_______________: • Estado Civil : ______________________________ Ocupación_________________________: • Padre : __________________________________________ Edad:____________________ • Madre : __________________________________________ Edad:____________________ • Referente : ______________________________________________________________________ • Informantes : ______________________________________________________________________ • Lugar de Eval._____________________________________________________________________: • Sexo : ____________ Edad :___________ Fecha de Nac. Datos De Filiación: • Nom._________________________________: Procedencia_______: • Dirección : ______________________________________ Télf:________________________ • Grado de Inst.

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Diagnóstico o Conclusión. _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ VIII. Recomendaciones: ψ ___________________________________________________________________________________ ψ ___________________________________________________________________________________ ψ ___________________________________________________________________________________ ψ ___________________________________________________________________________________ ψ ___________________________________________________________________________________ ψ ___________________________________________________________________________________ ψ ___________________________________________________________________________________ ψ ___________________________________________________________________________________ ψ ___________________________________________________________________________________ ψ . _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ IX. Análisis e Interpretación de los Resultados._______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ VI. Pronóstico. _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ VII.

y Apell.________________________________________________________________: • Sexo : ____________ Edad :___________ Fecha de Nac.PLAN PSICOTERAPEÚTICO I._________________________________: Procedencia__: • Dirección : ______________________________________ Télf:___________________ • Grado de Inst.________________________________: Religión__________: • Estado Civil : ______________________________ Ocupación____________________: • Padre : __________________________________________ Edad:_______________ • Madre : __________________________________________ Edad:_______________ • Referente : _________________________________________________________________ • Informantes : _________________________________________________________________ • Lugar de Eval. Técnicas Terapéuticas: ψ ψ ψ ψ ψ ψ ψ ψ . Datos de Filiación: • Nom.______________________________________________________________: • Examinador : Psicólogo Jorge Luis Fernández Salguero.______________: • Lugar de Nac. Diagnóstico Psicológico: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ III. Objetivos Generales: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ IV. II. Objetivos Específicos: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ V._______________________________________________________________: • Fechas de Eval.

VI. Actividades Psicoterapéuticas: SESIÓ N TÉCNICAS REALIZADAS “ P R I M E R A ” Objetivos Acciones Especificas ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ SESIÓ N TÉCNICAS REALIZADAS “ S E G U N D A ” Objetivos Acciones Especificas ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ SESIÓ N TÉCNICAS REALIZADAS “ T E R C E R A ” Objetivos Acciones Especificas ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ .

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SESIÓ N TÉCNICAS REALIZADAS “ C U A R T A ” Objetivos Acciones Especificas ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ SESIÓ N TÉCNICAS REALIZADAS “ Q U I N T A ” Objetivos Acciones Especificas ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ SESIÓ N TÉCNICAS REALIZADAS “ S E X T A ” Objetivos Acciones Especificas ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ .

SESIÓ N TÉCNICAS REALIZADAS “ S E P T I M A ” Objetivos Acciones Especificas ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ SESIÓ N TÉCNICAS REALIZADAS “ O C T A V A ” Objetivos Acciones Especificas ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ SESIÓ N TÉCNICAS REALIZADAS “ N O V E N A ” Objetivos Acciones Especificas ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ SESIÓ N TÉCNICAS REALIZADAS “ Objetivos ” Acciones Especificas ____________________________ ___________________________________________________ .

VII. Avances y Logros Terapéuticos: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Arequipa de del 2010 . Tiempo de Ejecución: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ VIII.