Historia Clínica Menores de Edad - 1

PLAN DE INVERVENSIONES COLECTIVAS (PIC)

ATENCIÓN PSICOLÓGICA

HISTORIA CLÍNICA MENORES DE EDAD

Fecha de Diligenciamiento
Hora
Historia Clínica N°

NOMBRE ______________________________________________ EDAD _________ SEXO M__ F__

LUGAR Y FECHA DE NACIMIENTO _____________________________________________________
IDENTIFICACIÓN RC__ TI__ NI __ N° _________________________
DOMICILIO ______________________________________________ TELÉFONO _________________
ZONA RESIDENCIAL Urbana __ Rural __ MUNICIPIO DE RESIDENCIA ___________________
NOMBRE DEL TUTOR _____________________________________ TELÉFONO _________________
CORREO ELECTRÓNICO ______________________________________________________________
ESCOLARIDAD Primaria ___ Secundaria __ Bachiller __ Otro ____
ASEGURADORA ______________________________ TIPO DE VINCULACIÓN __________________
Genográma

1.1. Motivo de consulta y otros problemas (consultante)

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1.2. Motivo de consulta y otros problemas (acompañante)

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2. Análisis del problema en la actualidad (evaluación del nivel de afectación con respecto al
inicio del problema; frecuencia, intensidad, duración)
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3. Historia del Problema (incluir soluciones intentadas y resultados)

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3. Esferas de Funcionamiento Afectadas o Involucradas en el problema: (personal,

familiar, social, académica, afectiva o de pareja, laboral)

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4. Antecedentes médicos, psiquiátricos, de desarrollo o personales significativos

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5. Antecedentes familiares (médicos y/o Psiquiátricos)

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6. Recursos y limitaciones del consultante

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7. Motivación, Objetivos y expectativas frente a la atención Psicológica

(consultante/familia/otros)
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8. Observaciones (Incluir aspectos relevantes tales como descripción del paciente, síntomas
exacerbados, conciencia frente al problema, actitud familiar, aspectos a profundizar, etc.)
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Firma profesional Psicólogo a cargo
T.P.