Documentos de Académico
Documentos de Profesional
Documentos de Cultura
Entrevistador: __________________________
Ficha de Identificacin.
Nombre:
Edad:
Sexo:
Estado Civil:
Ocupacin:
Escolaridad:
Domicilio:
Religin:
Familiar responsable:
Impresin diagnstica.
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Antecedentes familiares.
Parentesco
Edad
Escolaridad
Abuelo:
Abuela:
Padre:
Madre:
Hermanos/as:
Ocupacin
Condicin
actual de
salud
Enfermedades
Mdicas o
Psiquitricas
Adicciones
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Antecedentes personales.
Rentada ( )
Prestada ( )
Otro ( ) Especificar___________
Nmero de habitaciones:
Agua potable ( )
TV de paga ( )
Gas estacionario ( )
Regadera ( )
Computadora ( )
Lavadora de ropa ( )
Pescado ( )
Huevo ( )
Si ( )
No ( )
Fruta ( )
Verdura ( )
Leche ( )
Si ( )
No ( )
Si ( )
No ( )
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Antecedentes ginecobsttricos:
Menarca, inicio vida sexual activa, embarazos, partos, cesreas, abortos, mortinatos, menopausia
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Sexualidad:
Vivencias en torno al gnero, vnculos afectivos, reproductividad y erotismo
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Padecimiento actual.
Motivo de la entrevista:
Inicio de la sintomatologa o padecimiento, impacto del padecimiento, acciones realizadas y
efectividad de las mismas, historial de atencin mdica o psiquitrica y expectativas
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Repercusiones:
Consecuencias en las reas conyugal, familiar, laboral, social, econmica y social
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Historia farmacolgica:
Examen Mental
Conducta y aspecto general.
Grado de orientacin.
tiempo, persona y lugar
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Atencin y concentracin:
Memoria:
Amnesias hacia eventos particulares, perodos de tiempo, eventos recientes o remotos, actitud del
paciente ante lo olvidado, capacidad (hacer repetir un nombre, direccin, etc. inmediatamente y
despus de cinco minutos pedir que lo repita nuevamente)
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Inteligencia:
Vocabulario, conocimientos diversos sobre cultura, capacidad de abstraccin
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Aspecto formal del lenguaje y curso del pensamiento (fuga de ideas, bloqueos, disociaciones,
reiteraciones, perseverancia, incoherencias, neologismos, transcribir literalmente )
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Iniciacin, contenido, grado de credibilidad, intensidad con la que lo vive (en relacin al ambiente,
al cuerpo o a s mismo), alteraciones de sensopercepcin (en relacin al ambiente, al cuerpo o al
yo)
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Afectividad.
Nivel de congruencia entre el afecto y el contenido del discurso, aplanamiento afectivo, labillidad
emocional. Indagar sobre ideas, planeacin e intentos suicidas
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Juicio.
Actitudes y expectativas
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Personalidad.
Relaciones interpersonales:
Actitudes hacia las relaciones, facilidad o dificultad para hacerlas o mantenerlas
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Humor y nimo:
Habilidades para expresar y controlar emociones
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Fantasas:
Impactantes, repetitivas, recientes
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Rasgos de carcter:
Influencia de factores genticos, ambientales y tendencias dominantes de carcter
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Aspectos Psicodinmicos.
Motivos profundos:
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Tests Aplicados.
Test
Resultado
Diagnstico.
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Bibliografa
Aragn, L. y Silva, A. (2002). Fundamentos tericos de la evaluacin psicolgica.
Mxico: Ed. Pax.
Jacas, Carlos. Protocolos de evaluacin neuropsicolgica en Psicogeriatra.
Informaciones Psiquitricas Segundo semestre 2008. Nmero 192. Disponible
en: http://www.revistahospitalarias.org/info_2008/02_192_07.htm