HISTORIA CLINICA

Fecha: ________________
Informante: _________________________________

I.

DATOS DE IDENTIFICACIN

Nombre y Apellido: _________________________________________________

Edad: ____

Cdula de Identidad: ________________

Estado Civil:__________

Hijos: ____________________________

Escolaridad:______________

Ocupacin:_____________________

Religin: _________________________
Direccin:
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Telfono: __________________________

II. MOTIVO DE CONSULTA

Manifiesto y Latente
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III.

SITUACIN ACTUAL

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IV. EXAMEN MENTAL

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V.

GENOGRAMA

VI. ANTECEDENTES
Familiares:
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Psiquitricos:
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Mdicos:
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Pareja:
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VI.
COMPRENSIN DEL CASO
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VIII. EVALUACIN MULTIAXIAL DSM IV

EJE I
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EJE II
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EJE III
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EJE IV
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EVALUACIN DSM V
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DIAGONSTICO CIE-10
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IX. IMPRESIN DIAGNSTICA

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X. PLAN PSICOTERAPEUTICO
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