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FORMULARIO EVALUACION PSIQUIATRICA FECHA:______________

FICHA:______________
DATOS DE IDENTIFICACION
NOMBRE_____________________________________________________________________
EDAD/FN________________________RUT____________________ESTADO CIVIL___________
DIRECCIÓN______________________________________________COMUNA______________
EDUCACION_______________________________________OCUPACIÓN__________________
TELÉFONO______________________F/I________________RELIGIÓN____________________
ETNIA _________________________FAMILIAR RESPONSABLE___________________________
MOTIVO DE CONSULTA ACTUAL
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ANAMNESIS
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RESUMEN DE FICHA CLINICA
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ORIGEN DE DERIVACION:
HOSPITAL:_________Tribunales_______ Enlace________ APS___________Otro____________

ANTECEDENTES PERSONALES MEDICOS:


HTA _________EPI _________DM___________Tiroides ___________OTRA
Partos _________________Abortos_________ ACO
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Cirugia:_____________________________________________________________________
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Alergia o
RAM__________________________________________________________________
FARMACOS EN USO ACTUALMENTE
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ANTECEDENTES PERSONALES PSIQUIÁTRICOS: (Depresión Postparto)
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ANTECEDENTES FAMILIARES (Médicos y Psiquiátricos) _________________________________
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ANTECEDENTES DE CONSUMO de sustancias (edad de inicio, cantidades y tiempo de consumo)
Tabaco ________________ Alcohol _________________ THC/PB/Cocaína_______________
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GENOGRAMA (integrantes, nombres, edad y rol) (niños menores de 5 años)

EX. MENTAL:
1. Conciencia y Orientación__________________________________________________
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2.- Aspecto y conducta________________________________________________________
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3.- Animo__________________________________________________________________
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4.- Afectividad_______________________________________________________________
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5.- Pensamiento.
Curso __________________________________________________________________
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Contenido ______________________________________________________________
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6.-Sensopercepción __________________________________________________________
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7.- Psicomotilidad ___________________________________________________________
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8.- Juicio de realidad__________________________________________________________
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9.- Riesgo Suicidia____________________________________________________________
HIPOTESIS DIAGNOSTICA
Eje I ________________________________________________________________
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Eje II ________________________________________________________________
Eje III ________________________________________________________________
Eje IV ________________________________________________________________
Eje V (%)_______________________________________________________________
PLAN DE TRATAMIENTO
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REFLEXIÓN SOBRE CASO CLÍNICO (psicopatología, concordancia con historia, diagnóstico y
tratamiento)___________________________________________________________________
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