UNIVERSIDAD NACIONAL AUTNOMA DE MXICO

FACULTAD DE PSICOLOGA EE
CENTRO DE SERVICIOS PSICOLGICOS
RESIDENCIA EN MEDICINA CONDUCTUAL

Entrevista de Exploracin

EXPEDIENTE: ______________
FECHA: ____________________
I. FICHA DE IDENTIFICACIN
Nombre del paciente: ___________________________________________________________________
Edad: ______________ Sexo: ________________ Edo. Civil: ______________________
Calle: _____________________________________ No.Exterior:_______ No. Interior: ___________
Col._______________________________________ Del._____________________ C. P.___________
Tel. domicilio: _____________ Tel. trabajo: ______________ Recados: _______________________
Ubicacin hospitalaria: _________________________________________________________________
Dx. Mdico: __________________________________________________________________________
Dx. Psicolgico: _______________________________________________________________________
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Motivo de consulta: ____________________________________________________________________
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II HISTORIA DEL PROBLEMA.

DESCRIPCIN DE LA PRIMERA VEZ QUE SE PRESENTO EL PROBLEMA:

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III EXPLORACIN PARA LA IDENTIFICACIN DEL CASO.

NUMERO DE VECES QUE SE HA PRESENTADO EL PROBLEMA: ____________________________________

DESCRIPCION DE CADA UNA DE ELLAS: ________________________________________________________

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EN CADA OCASIN QU SE HIZO PARA RESOLVERLO?: __________________________________________

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DE QUE MANERA HA AFECTADO ESTE PROBLEMA SU VIDA (REAS)? ____________________________

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ACTUALMENTE CMO SE PRESENTA EL PROBLEMA?: ___________________________________________

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CONCLUSIONES DE LA PROBLEMTICA EXPUESTA: _____________________________________________

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MOTIVACIN AL TRATAMIENTO: _______________________________________________________________

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IV DETERMINACIN DEL CASO PARA ALGUN PROGRAMA.

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PROXIMA CITA: __________ __________ __________ __________

DIA MES AO HORA

PROBLEMAS PRESENTADOS EN LA SESION: _____________________________________________________

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SOLUCIONES ADOPTADAS: _____________________________________________________________________

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TERAPEUTA RESPONSABLE: _________________________

CO-TERAPEUTA: ____________________________________