UNIVERSIDAD ARTURO MICHELENA

CÁTEDRA PSICOPATOLOGÍA I

HISTORIA CLINICA

I- DATOS DE IDENTIFICACIÓN
Fecha:_______________ Entrevistador:______________________________________
Nombre y Apellido del entrevistado:_________________________________________
Fecha de nacimiento:________________________ Edad:________________________
Sexo:___________ Edo. Civil:_____________
Ocupación:_____________ Escolaridad:______________________
Dirección:_________________________________________
Religión:_______________________________________________________________

II- MOTIVO DE CONSULTA

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III- ENFERMEDAD ACTUAL

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IV- EXAMEN MENTAL
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V- ANTECEDENTES MORBIDOS PERSONALES (Psiquiátricos y Psicológicos)

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VI- ANTECEDENTES PSICOSOCIALES

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VII- ANTECEDENTES FAMILIARES

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VIII- GENOGRAMA

IX- SITUACIÓN ACTUAL Y HÁBITOS PSICOBIOLÓGICOS (ocupacional,

académica, vivienda, recreativa)
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X- IMPRESIÓN DIAGNÓSTICA
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XI- CONCLUSIÓN
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