HOSPITAL REGIONAL DE ICA

SERVICIO DE MEDICINA FÍSICA Y REHABILITACIÓN

PP 0129 PREVENCION Y MANEJO DE CONDICIONES SECUNDARIAS DE SALUD EN PERSONAS CON
DISCAPACIDAD
AREA DE PSICOLOGIA CLINICA

HISTORIA CLINICA

N°. H.C:____________
I. DATOS GENERALES:
NOMBRES Y APELLIDOS: ____________________________________________________________
SEXO: __________________ EDAD: __________
FECHA Y LUGAR DE NECIEMIENTO: ____________________________________________________
GRADO DE ESTUDIO: _______________________________________________________________
OCUPACION: _____________________________________________________________________
DIRECCION ACTUAL: _______________________________________________________________
ESTADO CIVIL: __________________________ RELIFION: _________________________________
INFORMANTE: ____________________________________________________________________
FECHA DE ENTREVISTA: _____________________________________________________________
EXAMINADOR: ____________________________________________________________________

II. MOTIVO DE CONSULTA:

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III. OBSERVACION DE LA CONDUCTA:
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IV. HISTORIA FAMILIAR:
-PAPA
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-MAMA
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 HOSPITAL REGIONAL DE ICA
SERVICIO DE MEDICINA FÍSICA Y REHABILITACIÓN
PP 0129 PREVENCION Y MANEJO DE CONDICIONES SECUNDARIAS DE SALUD EN PERSONAS CON
DISCAPACIDAD
AREA DE PSICOLOGIA CLINICA

-ABUELOS
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V. HISTORIA PERSONAL
-EMBARAZO
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-PARTO
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-DESARROLLO PSICOMOTOR (sentarse, hablar, control de esfínteres)
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-INFANCIA
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-ESCOLARIDAD
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-ADOLESCENCIA
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-VIDA SEXUAL (inicio, quien, orientación, N° de parejas formales, ocasionales, protección)
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-JUVENTUD
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 HOSPITAL REGIONAL DE ICA
SERVICIO DE MEDICINA FÍSICA Y REHABILITACIÓN
PP 0129 PREVENCION Y MANEJO DE CONDICIONES SECUNDARIAS DE SALUD EN PERSONAS CON
DISCAPACIDAD
AREA DE PSICOLOGIA CLINICA

-ADULTEZ
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-ENFERMEDADES, ACCIDENTES, OPERACIONES
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-HABITOS E INTERESES (además uso de drogas, alcohol, ludopatía)
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-TRABAJO Y OCUPACION
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VI. SITUACION SOCIECONOMICA
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VII. CARACTERISTICAS GENERALES DEL COMPORTAMIENTO
-DESCRPCION FISICA
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-NIVEL DE CONCIENCIA
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-ESTADO EMOCIONAL
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-MOTRICIDAD
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-INTERACCION SOCIAL
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 HOSPITAL REGIONAL DE ICA
SERVICIO DE MEDICINA FÍSICA Y REHABILITACIÓN
PP 0129 PREVENCION Y MANEJO DE CONDICIONES SECUNDARIAS DE SALUD EN PERSONAS CON
DISCAPACIDAD
AREA DE PSICOLOGIA CLINICA

VIII. PROCESOS COGNITIVOS:

-ORIENTACION, ESPACIO, TIEMPO, PERSONA
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-ATENCION Y CONCENTRACION
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-PERCEPCION
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-MEMORIA
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-PENSAMIENTO
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-LENGUAJE
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-INTELIGENCIA
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IX. CARÁCTER, SENTIMIENTOS Y ACTITUDES
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X. APLICACIÓN DE PRUEBAS (TEST PSICOLOGICOS)
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 HOSPITAL REGIONAL DE ICA
SERVICIO DE MEDICINA FÍSICA Y REHABILITACIÓN
PP 0129 PREVENCION Y MANEJO DE CONDICIONES SECUNDARIAS DE SALUD EN PERSONAS CON
DISCAPACIDAD
AREA DE PSICOLOGIA CLINICA

XI. IMPRESIÓN DIAGNOSTICA

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XII. RECOMENDACIONES
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