Universidad Santo Tomás

Facultad de Ciencias sociales

Escuela de Psicología
Ayudantía Ev. Psicológica Cognitiva

FICHA CLINICA 2019

I- ANTECEDENTES PERSONALES

NOMBRE : _____________________________________________________
APELLIDOS : _____________________________________________________
RUT : _____________________________________________________
FECHA DE NACIMIENTO : _____________________________________________________
EDAD : _____________________________________________________
SEXO : _____________________________________________________
ESCOLARIDAD : _____________________________________________________
OCUPACIÓN : _____________________________________________________
ESTADO CIVIL : _____________________________________________________
DOMICILIO : _____________________________________________________
COMUNA : _____________________________________________________
TELÉFONO : _____________________________________________________
EMAIL : _____________________________________________________

II- ORIGEN

DERIVADO POR : _____________________________________________________

III- ANTECEDENTES PSICÓLOGO(A) E INTERVENCIÓN

NOMBRE PSICÓLOGO(A) : _____________________________________________________

TIPO DE INTERVENCIÓN : _____________________________________________________
HORARIO DE ATENCIÓN : _____________________________________________________

IV- MOTIVO DE CONSULTA

SEGÚN INSTITUCIÓN O
PROFESIONAL QUE DERIVA :

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SEGÚN CONSULTANTE :

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VI- EXPECTATIVAS

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VII-OTROS ANTECEDENTES

PSICÓSIS : SI____ NO____ / ____________________________________________

ABUSO DE SUSTANCIAS : SI____ NO____ / ____________________________________________
TRAST. DE ALIMENTACIÓN : SI____ NO____ / ____________________________________________
VIOLENCIA Y/O ABUSO : SI____ NO____ / ____________________________________________

VIII- EVALUACIÓN RIESGO SUICIDA

IDEACIÓN : SI____ NO____ / PASADA____ ACTUAL____

PLAN : SI____ NO____ / PASADA____ ACTUAL____
INTENTO : SI____ NO____ / PASADA____ ACTUAL____

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IX- ANTECEDENTES SOCIOFAMILIARES

FAMILIA ACTUAL

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FAMILIA DE ORIGEN

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GENOGRAMA

X- ANTECEDENTES SOCIALES

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XI- OTROS ANTECEDENTES RELEVANTES

ANTECEDENTES MÓRBIDOS

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TRATAMIENTO FARMACOLÓGICO ACTIVO (Incluido autoprescripciones)
SI____ NO____

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ANTECEDENTES LABORALES Y/O ACADEMICOS RELEVANTES

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OBSERVACIÓN CLÍNICA

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XI-HIPÓTESIS DIAGNÓSTICA