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HISTORIA CLINICA
CD, JUAREZ,CHIH,.A ________________
A)DATOS PERSONALES
NOMBRE:_____________________________________________________________________
EDAD:___________

FECHA DE NAC: ___________________

EDO.CIVIL_____________

OCUPACION:_______________

SEXO:________

TELEFONO:____________

DOMICILIO: ___________________________________________________________________
ESCOLARIDAD:_____________

N DE HIJOS: ____________ RELIGION______________

LUGAR DE NACIMIENTO.-________________ TIEMPO DE RESIDIR EN LA CIUDAD________

NUMERO DE HERMANOS_________________

LUGAR QUE OCUPA _________________

DESCRIPCION GENERAL DEL PACIENTE

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B) RAZON DE EVALUACION.- Perspectiva del problema a travs de las palabras de:
PACIENTE_____________________________________________________________________
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FAMILIA_______________________________________________________________________
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CONYUGE_____________________________________________________________________
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MEDICO_______________________________________________________________________
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TERAPEUTA___________________________________________________________________
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C) PADECIMIENTO ACTUAL: Descripcin general del padecimiento desde el inicio hasta el
momento actual y sus razones para consultar. Historia de visitas a otros terapeutas y tipos de
tratamiento, asi como sus resultados.
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D)HISTORIA PERSONAL

ANTECEDENTES

COMPORTAMIENTO ANTERIOR AL PADECIMIENTO_________________________________

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INFANCIA

PADECIMIENTOS O ENFERMEDADES DE LA INFANCIA:______________________________

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INFANCIA TEMPRANA: Aspectos generales de embarazo, parto, tipo de nacimiento, etc.
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CARACTER Y COMPORTAMIENTO DE LA INFANCIA TARDIA.- Tipo de nio, juegos,

miedos, fobias, pesadillas, ambiente familiar, etc.
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ADOLESCENCIA

PADECIMIENTOS O ENFERMEDADES EN LA ADOLESCENCIA: ________________________

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TIPO DE COMPORTAMIENTO.- Percepcin de los cambios fsicos, educacin sexual, etc.
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RELACION CON SUS PADRES:__________________________________________________
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RELACION CON SUS AMIGOS:___________________________________________________
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RELACION CON SU FAMILIA:____________________________________________________
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EXPERIENCIA ESCOLAR:_______________________________________________________
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EXPERIENCIAS ESPECIALES:____________________________________________________
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TIPO DE CARCTER.- __________________________________________________________

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EDAD ADULTA

PADECIMIENTOS O ENFERMEDADES: ____________________________________________

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TIPO DE CARACTER:___________________________________________________________
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ACTIVIDADES DE TIEMPO LIBRE_________________________________________________
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PADECIMIENTOS O ENFERMEDADES DE FAMILIARES U OTRAS PERSONAS CERCANAS_
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COMPORTAMIENTO EN SU TRABAJO_____________________________________________
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METAS U OBJETIVOS EN LA VIDA________________________________________________
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FRACASOS ___________________________________________________________________
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VIDA SEXUAL_________________________________________________________________
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SENTIMIENTOS COMO PADRE:__________________________________________________
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SENTIMIENTOS COMO ESPOSO (A):______________________________________________

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SENTIMIENTOS COMO HOMBRE:_________________________________________________
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DINAMICA FAMILIAR ACTUAL____________________________________________________
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D. ANTECEDENTES GENERALES
DROGADICCION_______________________________________________________________
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ALCOHOLISMO________________________________________________________________
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PROBLEMAS MENTALES________________________________________________________
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TEMORES NOCTURNOS:________________________________________________________
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MIEDOS______________________________________________________________________
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TARTAMUDEZ_________________________________________________________________
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FOBIAS_______________________________________________________________________
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TIMIDEZ EXCESIVA____________________________________________________________
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PESADILLAS__________________________________________________________________
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DIFICULTADES DE SUEO______________________________________________________
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SONAMBULISMO:_____________________________________________________________
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RABIETAS:____________________________________________________________________
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ENURESIS:___________________________________________________________________
ENCOPRESIS:_________________________________________________________________

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ONICOFAGIA: _________________________________________________________________
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GOLPES EN LA CABEZA:________________________________________________________
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TIPO DE NACIMIENTO:-_________________________________________________________
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PROBLEMAS EN EL NACIMIENTO.-_______________________________________________
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OTROS_______________________________________________________________________
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E. DATOS FAMILIARES
FAMILIOGRAMA

NOMBRE DEL CONYUGE:_______________________________________________________

EDAD:_________

OCUPACION:________________________________________________

AOS DE CASADOS:_______ RELIGION:____________

VIVO:_____

MUERTO:______

ESTADO ACTUAL DE SALUD:____________________________________________________

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TIPO DE CARACTER___________________________________________________________
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TIPO DE RELACION QUE LLEVA CON EL:__________________________________________
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DOMICILIO
TELEFONO
FECHA DE NAC.___/_____/_____LUGAR DE NAC.___________ TIEMPO EN LA CIUDAD____
ESCOLARIDAD_______________________

LUGAR EN LA FAMILIA_________________

HABITOS_____________________________________________________________________
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ACTIVIDADES EN SU TIEMPO LIBRE______________________________________________
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ANTECEDENTES PATOLOGICOS U OBJETOS DE OBSERVACION______________________
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ANTECEDENTES FAMILIARES PATOLOGICOS U OBJETOS DE OBSERVACION__________
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RELACION CON LOS FAMILIARES DE EL (ELLA)____________________________________
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NOMBRE DEL PADRE:___________________________________________________
EDAD:_________

OCUPACION:________________________________________________

AOS DE CASADOS:_______ RELIGION:____________

VIVO:_____

MUERTO:______

ESTADO ACTUAL DE SALUD:____________________________________________________

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TIPO DE CARACTER___________________________________________________________

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TIPO DE RELACION QUE LLEVA CON EL___________________________________________
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DOMICILIO
TELEFONO
FECHA DE NAC.___/_____/_____LUGAR DE NAC.___________ TIEMPO EN LA CIUDAD____
ESCOLARIDAD_______________________

LUGAR EN LA FAMILIA_________________

HABITOS_____________________________________________________________________
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ACTIVIDADES EN SU TIEMPO LIBRE______________________________________________
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ANTECEDENTES PATOLOGICOS U OBJETOS DE OBSERVACION______________________
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ANTECEDENTES FAMILIARES PATOLOGICOS U OBJETOS DE OBSERVACION__________
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RELACION CON SU FAMILIA PATERNA____________________________________________
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NOMBRE DE LA MADRE:_________________________________________________
EDAD:_________

OCUPACION:________________________________________________

AOS DE CASADOS:_______ RELIGION:____________

VIVO:_____

MUERTO:______

ESTADO ACTUAL DE SALUD:____________________________________________________

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TIPO DE CARACTER___________________________________________________________
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TIPO DE RELACION QUE LLEVA CON EL___________________________________________
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DOMICILIO
TELEFONO
FECHA DE NAC.___/_____/_____LUGAR DE NAC.___________ TIEMPO EN LA CIUDAD____
ESCOLARIDAD_______________________

LUGAR EN LA FAMILIA_________________

HABITOS_____________________________________________________________________
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ACTIVIDADES EN SU TIEMPO LIBRE______________________________________________
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ANTECEDENTES PATOLOGICOS U OBJETOS DE OBSERVACION______________________
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ANTECEDENTES FAMILIARES PATOLOGICOS U OBJETOS DE OBSERVACION__________
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RELACION CON SU FAMILIA PATERNA____________________________________________
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HERMANOS DEL PACIENTE
NOMBRE

EDAD

1. ___________________________________________________________________________
2.-___________________________________________________________________________
3.- ___________________________________________________________________________
4. ___________________________________________________________________________
5.- .__________________________________________________________________________
6.- .__________________________________________________________________________

ANTECEDENTES PATOLOGICOS U OBJETO DE OBSERVACION_______________________

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RELACION CON CADA UNO DE ELLOS____________________________________________

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OTRAS PERSONAS QUE CONVIVEN CON EL PACIENTE EN EL HOGAR
NOMBRE

PARENTESCO

OCUPACION

EDAD

F. EXAMEN MENTAL
TIEMPO, LUGAR Y ESPACIO_____________________________________________________
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EXAMEN FISICO_______________________________________________________________
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EXAMEN NEUROLOGICO________________________________________________________
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EXAMENES DE LABORATORIO O GABINETE_______________________________________
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IMPRESIN Y APARIENCIA EN GENERAL.- Apariencia personal, edad que representa, uso de
ropa, marcha, postura, complexin y constitucin, reaccin hacia el terapeuta, etc.
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AREA PERCEPTUAL.- Atencin, concentracin, orientacin, edo. De conciencia, etc.
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AREA INTELECTUAL.- Curiosidad o capacidad de observacin y exploracin, memoria reciente
y remota, nivel intelectual, conocimientos generales, juicios, organizacin, coherencia, capacidad
de abstraccin, nivel de introspeccin, lenguaje y comunicacin, fluidez, caractersticas de la voz,
etc.
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EMOCIONES Y AFECTIVIDAD.- Lo que siente el paciente, cmo lo expresa, estado de nimo,
irritabilidad, comunicacin no verbal, etc.
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ACCION MOTORA.- Nivel de energa, habilidades, planeacin y tiempo, propositos, etc.

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G. SINTOMAS
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DIAGNOSTICO_________________________________________________________________
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PRONOSTICO_________________________________________________________________
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MODELO TERAPEUTICO________________________________________________________
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PRUEBAS PSICOMETRICAS APLICADAS Y RESULTADOS____________________________
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APLICO_______________________________________________________________________________
FUENTE DE REFERENCIA_____________________________________________________________
OBSERVACIONES Y COMENTARIOS___________________________________________________
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