Diana C Gómez Miranda

Magister en Profundización Clínica

Universidad del Norte

HISTORIA CLINICA

1. DATOS DE IDENTIFICACIÓN:
Nombre y Apellido: ________________________________________________________________
Sexo: ___________________
Fecha de Nacimiento: ______________________________________
Edad: _________________________
Escolaridad: ____________________________
Nivel Socio-económico: _______________________________________
Religión: _______________________________________
Nombre del Padre: ________________________________________ Edad: _______
Ocupación: ____________________________________________________________
Nombre de la Madre: _____________________________________________ Edad: _________
Ocupación: _____________________________________________________________
Dirección: _____________________________________________________________
Número de Hermanos: _____________ Lugar que ocupa: ____________
Nombre Genero Edad Escolaridad

Mapa Familiar:
 Diana C Gómez Miranda
Magister en Profundización Clínica
Universidad del Norte

2. MOTIVO DE CONSULTA:
Según docente:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Según sus padres:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Según el Niño:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

3. CONTACTO INICIAL:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
 Diana C Gómez Miranda
Magister en Profundización Clínica
Universidad del Norte
4. ANTECEDENTES DEL MOTIVO DE CONSULTA:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

5. ANÁLISIS HISTÓRICO:
HISTORIA FAMILIAR:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
 Diana C Gómez Miranda
Magister en Profundización Clínica
Universidad del Norte

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

6. HISTORIA PERSONAL:
Embarazo y parto:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Lactancia:
________________________________________________________________________________________
________________________________________________________________________________________
Desarrollo Psicomotor:
________________________________________________________________________________________
________________________________________________________________________________________
Lenguaje:
________________________________________________________________________________________
________________________________________________________________________________________

Alimentación:
________________________________________________________________________________________
________________________________________________________________________________________
 Diana C Gómez Miranda
Magister en Profundización Clínica
Universidad del Norte
Escolaridad:
________________________________________________________________________________________
________________________________________________________________________________________
Otros:
________________________________________________________________________________________
________________________________________________________________________________________
7. ANTECEDENTES MÉDICOS:
Patológicos:
Quirúrgicos:
Tóxicos:
Alergias:
8. DESCRIPCIÓN PERSONAL:
Relaciones Sociales:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Actividades e intereses:
________________________________________________________________________________________
________________________________________________________________________________________
Humor y Carácter:
________________________________________________________________________________________
________________________________________________________________________________________
Hábitos:
________________________________________________________________________________________
________________________________________________________________________________________
ABC:
________________________________________________________________________________________
________________________________________________________________________________________
 Diana C Gómez Miranda
Magister en Profundización Clínica
Universidad del Norte
EXAMEN MENTAL:

A) FUNCIONES DE RELACIÓN:

Apariencia General:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Conciencia:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Sueño:
________________________________________________________________________________________
________________________________________________________________________________________

B) FUNCIONES INTELECTIVAS:

Atención:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

Orientación:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
 Diana C Gómez Miranda
Magister en Profundización Clínica
Universidad del Norte
Memoria:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Senso- Percepción:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Pensamiento:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Esfera Afectiva:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
C) FUNCIONES DE SÍNTESIS:

Inteligencia:
________________________________________________________________________________________
________________________________________________________________________________________
Conductas:
________________________________________________________________________________________
________________________________________________________________________________________
 Diana C Gómez Miranda
Magister en Profundización Clínica
Universidad del Norte
9) IDENTIFICACIÓN DE PROBLEMAS

P1:
P2:
P3:
P4:

10) ANÁLISIS DESCRIPTIVO:

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
11) ANÁLISIS FUNCIONAL

ANTECEDENTE- RESPUESTA CONSECUENCIA

(SITUACIÓN)
 Diana C Gómez Miranda
Magister en Profundización Clínica
Universidad del Norte

ANTECEDENTE- RESPUESTA CONSECUENCIA

(SITUACIÓN)

12) ANÁLISIS DE VARIABLES:

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

13) METÁNALISIS O ANÁLISIS MOLAR DE LOS PROBLEMAS:

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
 Diana C Gómez Miranda
Magister en Profundización Clínica
Universidad del Norte

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

14) EVALUACIÓN E INSTRUMENTOS:

15) RESUMEN DE RESULTADOS DE LA EVALUACIÓN:

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
16) EVALUACIÓN NO AXIAL DSM V:
 Diana C Gómez Miranda
Magister en Profundización Clínica
Universidad del Norte
17) OBJETIVO TERAPEUTICO:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

18) PLAN O DISEÑO DEL TRATAMIENTO:

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
19) OBSERVACIONES Y RECOMENDACIONES:

________________________________________________________________________________________
________________________________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Responsable: Diana C Gómez Miranda.

TP: 134297
Psicoterapeuta Infantil.
Magister en Psicología, Profundización Clínica Cognitiva- Conductual.
Especialista en Psicología Clínica- Cognitivo Conductual.