Universidad Mariano Glvez

Centro Regional, Coatepeque

Walter Alexander de Paz O.
FICHA CLNICA DE NIOS
I.

DATOS DE IDENTIFICACIN PERSONAL:

Nombre
completo
del
paciente:_______________________________________________
Edad:
______________Sexo:
_______________
Fecha
de
nacimiento:________________
Direccin:____________________________________Tels:______________________
__
Nombre
de
la
madre:
___________________Edad:_______________________________
Nombre
del
padre:
_____________________Edad:_______________________________
Ocupacin
del
padre:
________________________Escolaridad:____________________
Ocupacin
de
la
madre:
______________________Escolaridad:____________________
No.
de
hermanos:
_________________
Lugar
que
ocupa:__________________________
Es hijo de padres divorciados o separados?___________________________________
Religin
que
profesa:_______________________________________________________
Fecha
de
Consulta:_________________________________________________________
Nombre
del
acompaante
en
la
entrevista:_____________________________________
Parentesco
del
acompaante:________________________________________________
Motivo
de
consulta:________________________________________________________
Por
quin
fue
referido?
____________________________________________________
Recibi
otras
terapias?
____________________________________________________
Tiene
tratamiento
mdico?
_________________________________________________
FECHA DE INICIO Y DURACIN DEL PROBLEMA:
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__
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FACTORES PRECIPITANTES:
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_
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_________________________________
IMPACTO DEL TRASTORNO EN EL SUJETO Y EN LA
FAMILIA:___________________________________________________________________________
_
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Universidad Mariano Glvez

Centro Regional, Coatepeque
Walter Alexander de Paz O.
_________________________________

II.

HISTORIAL CLNICO

Qu enfermedades ha padecido desde su nacimiento?

Tiene las siguientes vacunas?
Sarampin______________
B_______________
Poliomielitis_____________
B.C.G.__________________

D.P.T.__________________

Hepatitis

D.P.____________________
T.T.____________________

III.

CONDICIN DEL EMBARAZO

Naci a los 9 meses?____________________ 7 meses?

_______________________________
El parto fue normal?_________ Por Cesrea?__________ Utilizaron frceps?
____________
Hubo alguna complicacin en el proceso del embarazo?
Si____________ No
__________
Cul?
_______________________________________________________________________
_
Ha tenido abortos, y cuntos?
_____________________________________________________
Tubo hemorragias durante el embarazo?
_____________________________________________
Padeci alguna infeccin o enfermedad durante el embarazo?
____________________________
_____________________________________________________________________________________
_

Ingiri algn medicamento durante el embarazo?

______________________________________
Cunto tiempo dur en labor de parto?
______________________________________________
El nio llor pronto:______________ Respir
inmediatamente:___________________________
Naci
amarillo
o
________________________________________________________
Hubo sufrimiento fetal?
__________________________________________________________
Peso y medida a la hora de
nacer:___________________________________________________
Fue un embarazo deseado?

morado?

Universidad Mariano Glvez

Centro Regional, Coatepeque
Walter Alexander de Paz O.
_______________________________________________________
IV. HISTORIA FAMILIAR:
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Universidad Mariano Glvez

Centro Regional, Coatepeque
Walter Alexander de Paz O.
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GENOGRAMA:

Universidad Mariano Glvez

Centro Regional, Coatepeque
Walter Alexander de Paz O.

V. ASPECTO SOCIAL

Es
extrovertido?
_______________________________________________________________
Es
introvertido?
________________________________________________________________
Es
comunicativo?
______________________________________________________________
Se enoja fcilmente?
____________________________________________________________
Cmo
es
la
relacin
con
sus
hermanos?
_____________________________________________
Cmo
es
la
relacin
con
sus
compaeros
de
clase?
____________________________________
_______________________________________________________________________
______
Con
quines
acostumbra
a
jugar?
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Universidad Mariano Glvez

Centro Regional, Coatepeque
Walter Alexander de Paz O.
__________________________________________________
_______________________________________________________________________
______
Cules
son
sus
juguetes
preferidos?
________________________________________________
_______________________________________________________________________
______
Juega
con
animales?
____________________________________________________________
Padece
enuresis?
_______________________________________________________________
Padece
encopresis?
_____________________________________________________________
Es
comunicativo?
______________________________________________________________

VI. ASPECTO PSICOLGICO

Es colrico?
___________________________________________________________________
Es nervioso?
__________________________________________________________________
Es aptico?
___________________________________________________________________
Pone atencin?
________________________________________________________________
Es obediente?
_________________________________________________________________
Es agresivo?
__________________________________________________________________
Tiene pesadillas nocturnas?
______________________________________________________
Es sonmbulo?
________________________________________________________________
Regularmente, se le ve sonrer?
___________________________________________________
Sufre de insomnio?
_____________________________________________________________
Llora de noche?
_______________________________________________________________
Es hiperactivo?
________________________________________________________________
Se succiona el dedo?
____________________________________________________________
Controla esfnteres?
____________________________________________________________
Se juega el pelo?
_______________________________________________________________

VI. EVOLUCIN DEL LENGUAJE

Universidad Mariano Glvez

Centro Regional, Coatepeque
Walter Alexander de Paz O.
Balbuce?
_____________________________________________________________________
Vocaliz en los primeros meses?
___________________________________________________
Edad en que dijo la primera palabra y primera
frase_____________________________________
_______________________________________________________________________
_______
Grado que
cursa_________________________________________________________________
Repiti algn grado?_____________________Por qu?
_______________________________
_______________________________________________________________________
______
Cmo es su adaptacin social?
____________________________________________________
_______________________________________________________________________
_______

I.

PLAN TERAPUTICO, TCNICAS, ESTRATEGIAS, MTODOS Y

RECOMENDACIONES: ______________________
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Universidad Mariano Glvez

Centro Regional, Coatepeque
Walter Alexander de Paz O.
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II.

NOTAS EVOLUTIVAS :
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Universidad Mariano Glvez

Centro Regional, Coatepeque
Walter Alexander de Paz O.
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Lugar y de la Entrevista: __________________________________________________

FIRMA:
______________________________________________________
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Universidad Mariano Glvez

Centro Regional, Coatepeque
Walter Alexander de Paz O.
WALTER ALEXANDER DE PAZ OROZCO:
SPTIMO SEMESTRE DE PSICOLOGA CLNICA
NMERO DE CARNET: 3772-12-1321

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