HISTORIA CLINICA DE PSICOLOGIA

N DE EXPEDIENTE
FECHA: ____________
NOMBRE DEL USUARIO: _______________________________________________
EDAD: ____________ SEXO: _____ 1 VEZ_______ SUBSECUENTE: __________
1. PADECIMIENTO ACTUAL: ___________________________________________
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1.1. DESCRIPCION BREVE DEL PROBLEMA: ______________________________
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CIRCUNSTANCIAS DE APARICION: _____________________________________
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SITUACION ACTUAL: __________________________________________________
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2. ANTECEDENTES PERSONALES.
2.1. AREA ESCOLAR: ___________________________________________________
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2.1.1. PROBLEMAS DE APRENDIZAJE (problemas en el aprendizaje de la lectoescritura, reprobacin escolar, problemas de conducta, rendimiento acadmico):
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2.2. AREA FAMILIAR: __________________________________________________

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2.2.1. CONSUMO O ABUSO DE DROGAS EN LA FAMILIA NUCLEAR: ________
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2.2.2. VIOLENCIA DOMESTICA (golpes entre los padres y/o contra los hijos y el
usuario, entre los hermanos, maltrato psicolgico hacia el usuario.):
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2.3. SEXUALIDAD: _____________________________________________________
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2.3.1. ABUSO SEXUAL (caricias, tocamiento sin llegar al coito por parte de los padres,
incesto entre hermanos y/o violacin):
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2.4. RELACIONES INTERPERSONALES: __________________________________
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2.5. AREA LABORAL: __________________________________________________
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2.6. HECHOS SIGNIFICATIVOS: _________________________________________
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3. EXAMEN MENTAL.
3.1. EXPLORACION DE EXAMEN MENTAL CLASICO (apariencia general,
orientacin, pensamiento, juicio, senso percepcin, afecto, estado de nimo, lenguaje,
memoria): ______________________________________________________________
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4. ACTITUDES FRENTE AL ENTREVISTADOR.
4.1. RELACION PSICOLOGO-USUARIO: __________________________________
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5. COMPLEMENTOS DIAGNOSTICOS.
5.1. INDICACIONES DIAGNOSTICAS:
PRUEBAS PSICOLOGICAS ___________________________________________
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VISITA DOMICILIARIA ______________________________________________

6. FAMILIOGRAMA:

OBSERVACIONES: _____________________________________________________
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NOMBRE DEL PSICOLOGO
RESPONSABLE

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FIRMA