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FICHA CLNICA

I. Datos personales

Nombre : ___________________ Domicilio : ___________________


Edad : ___________________ Telfono : ___________________
Fecha de nacimiento : ___________________ Nombre Profesor (a) :
Escolaridad : ___________________ Fecha de Ingreso : ___________________
Nombre de Apoderado : ___________________ Especialista : ___________________
II. Motivo de consulta

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III. Perfil

rea Somtica/biolgica

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rea Cognitiva

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rea afectiva

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rea Conductual

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rea Interpersonal/familiar

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Genograma:

IV. Diagnstico

-Eje I: Trastornos clnicos. Otros Problemas que pueden ser objeto de atencin.

Cdigo diagnstico Nombre (_ _ _-_ _)

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-Eje II: Trastorno de la personalidad. Retraso mental.

Cdigo diagnstico Nombre (_ _ _-_ _)


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-Eje III: Enfermedades mdicas

Cdigo diagnstico Nombre (_ _ _-_ _)

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-Eje IV: Problemas psicosociales y ambientales

o Problemas relativos al grupo primario de apoyo. Especificar________________________________

o Relativos al ambiente social. Especificar________________________________________________

o Relativos a la enseanza. Especificar___________________________________________________

o Relativo a lo laboral. Especificar______________________________________________________

o Relativo a vivienda. Especificar_______________________________________________________

o Relativo a lo econmicos. Especificar__________________________________________________

o Relativo al acceso a los servicios de asistencia sanitaria. Especificar__________________________

o Relativos a la interaccin con el sistema legal o con el crimen. Especificar_____________________

o Otros problemas psicosociales o ambientales. Especificar__________________________________

-Eje V: Escala de evaluacin de la actividad global.

Puntuacin : _______________

Perodo de tiempo : _______________