UNIVERSIDAD NACIONAL AUTÓNOMA DE MÉXICO

FACULTAD DE PSICOLOGÍA EE
CENTRO DE SERVICIOS PSICOLÓGICOS
RESIDENCIA EN MEDICINA CONDUCTUAL

Entrevista de Exploración

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

DESCRIPCIÓN DE LA PRIMERA VEZ QUE SE PRESENTO EL PROBLEMA:

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III EXPLORACIÓN PARA LA IDENTIFICACIÓN DEL CASO.

NUMERO DE VECES QUE SE HA PRESENTADO EL PROBLEMA: ____________________________________

DESCRIPCION DE CADA UNA DE ELLAS: ________________________________________________________

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EN CADA OCASIÓN ¿QUÉ SE HIZO PARA RESOLVERLO?: __________________________________________

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

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ACTUALMENTE ¿CÓMO SE PRESENTA EL PROBLEMA?: ___________________________________________

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CONCLUSIONES DE LA PROBLEMÁTICA EXPUESTA: _____________________________________________

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MOTIVACIÓN AL TRATAMIENTO: _______________________________________________________________

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IV DETERMINACIÓN DEL CASO PARA ALGUN PROGRAMA.

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PROXIMA CITA: __________ __________ __________ __________

DIA MES AÑO HORA

PROBLEMAS PRESENTADOS EN LA SESION: _____________________________________________________

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SOLUCIONES ADOPTADAS: _____________________________________________________________________

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TERAPEUTA RESPONSABLE: _________________________

CO-TERAPEUTA: ____________________________________