O.P.D.

SERVICIOS DE SALUD JALISCO

........................................INSTITUTO JALISCIENSE DE SALUD MENTAL
CENTRO INTEGRAL DE SALUD MENTAL

HISTORIA CLNICA
PSIQUIATRA CLNICA DEL NIO Y EL ADOLESCENTE
Ficha Clnica:
Fecha: _______________________ Hora: __________________________ Registro:________________________
Nombre: _______________________________________ Edad: _____________ Sexo: ____________________
Fecha de Nacimiento: ______________ Lugar de Nacimiento:______________________ ______________________
Escolaridad: _____________ Religin: ___________________ Escuela y Turno: ______________________ ________
Nombre del padre y/o tutor: ___________________________________
Edad: ________ Escolaridad y Ocupacin: ___________________________________________
Domicilio: _______________________________________________ Telfono: _____________________________
Nombre de la madre y/o tutor: _____________________________________
Edad: _____ Escolaridad y Ocupacin: _________________________________________________
Domicilio: ______________________ Telfono: _______________________________________________
Acompaante________________________________________________________________________________________
Referido por: _______________________________________ Derechohabiencia: _________________________________
Motivo de consulta:
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Padecimiento actual:
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Familia: (familiograma, dinmica familiar, integrantes)

Antecedentes Heredofamiliares:
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O.P.D. SERVICIOS DE SALUD JALISCO

INSTITUTO JALISCIENSE DE SALUD MENTAL
CENTRO INTEGRAL DE SALUD MENTAL
HISTORIA CLNICA
PSIQUIATRA CLNICA Y DEL ADOLESCENTE
Antecedentes personales patolgicos : _CIRUGIAS, ALERGIAS, HOSPITALIZACIONES , FRACTURAS,
TRANSFUSIONES, ESQUEMA DE VACUNACION .
Exploracin Fsica y SV: FC: ______ FR: ___ T: _____ Peso:_____Talla: ________ TA: ________ IMC
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ExamenMental:
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IDx. Multiaxial
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Pronstico: _________________________________________________________________________________________
Plan:
Farmacoterapia: ____________________________________________________________________
Psicologa:_________________________________________________________________________________________
Estudios: __________________________________________________________________________________________
Referencias y/o Interconsultas: _________________________________________________________
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NOMBRE Y CDULA DEL MDICO QUE REALIZ LA PRIMERA PARTE DE LA HISTORIA CLNICA.

O.P.D. SERVICIOS DE SALUD JALISCO

INSTITUTO JALISCIENSE DE SALUD MENTAL
CENTRO INTEGRAL DE SALUD MENTAL

HISTORIA CLNICA
PSIQUIATRA CLNICA Y DEL ADOLESCENTE

Antecedentes perinatales:
Producto de la gesta: ______de ____ G:_ _ P:__ _ C:__ A:____
Embarazo: ___ ________________
Nacimiento: _____________ Anestesia: __________________________________
Complicaciones:___________________________________________________________________________
Peso: _____Kg

Talla: _____cm

APGAR: __ __

Silverman: ______

Complicaciones perinatales:______________________________________ ___________________________

Desarrollo:
Maternaje: __________________________________________________________________________________________
SC: _meses__ Sedestacin: meses _ Gateo: ____ Bipedestacin: ___ meses ______ Deambulacin: ___ meses.__
Alteraciones: ____________________________________________________________ __________________________
Balbuceo cannico: __ meses _______ Palabras: _____ Frases simples: ______ Lenguaje completo: _____
Alteraciones: ________________________________________________________________________________________
Esfnteres: Anal: _____________ Vesical: ____________
Alteraciones: ________________________________________________________________________________________
Sonrisa social: ________________ Angustia ante extraos: ____________ Uso del NO:_______ ____________
Seno materno: _______ Ablactacin: _________ Dieta completa: _________________Selectividad alimentos: _________
Alteraciones:________________________________________________________________________________________

O.P.D. SERVICIOS DE SALUD JALISCO

....................................INSTITUTO JALISCIENSE DE SALUD MENTAL
CENTRO INTEGRAL DE SALUD MENTAL

HISTORIA CLNICA
PSIQUIATRA CLNICA Y DEL ADOLESCENTE

Desarrollo escolar: (A partir de guardera: desempeo, socializacin, cambios, relacin con figuras de autoridad,
motivos de suspensiones, proyectos).
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Intereses y pasatiempos: (videojuegos, uso de internet, actividad fsica y deportes).

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Desarrollo psicosexual y complicaciones:
Identificacin de Gnero: _____________________ Menarca: ______ _______________ FUR: _____________________
IVSA: ____________ Anticoncepcin: ____________ Conductas sexuales de riesgo: ______________________________
Antecedentes de abuso sexual: _______ __________________________________________________________________
Desarrollo simblico y personalidad:
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Uso de sustancias
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Recomendaciones complementarias:
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NOMBRE Y CDULA DEL MDICO QUE REALIZ LA PARTE FINAL DE LA HISTORIA CLNICA.