Historia Clínica

Datos de identificación:
Nombre y apellido del paciente: _______________________________________________
Lugar y fecha de nacimiento: _________________________________________________
Edad: ___________________________sexo:_________________C.I.________________
Grado de instrucción: ________________________Ocupación actual: ________________
Dirección de habitación: _____________________________________________________
____________________________________________Teléfono:_____________________
Dirección de empleo: _______________________________________________________
____________________________________________Teléfono: _____________________
Religión: ____________________________ Profesional Tratante: ___________________
Referido por : _____________________________ Fecha de consulta: ________________

Motivo de consulta (síntomas, inicio, severidad, porque busca tratamiento en

este momento, fuentes de referencia)
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Situación actual del paciente

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Contactos con otros profesionales. Tx. Ambulatorio, interno y

hospitalizaciones. Medicación pasada y presente.
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Antecedentes personales
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Antecedentes médicos
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Biografía
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Historia escolar
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Historia de relaciones interpersonales

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Historia conyugal
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Historia laboral
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Historia militar
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Historia familiar y su dinámica
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Genitograma

Historia de abusos, traumas, negligencia. Perdidas.

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Historia legal
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Hábitos psicobiológicos. Alimentación, eliminación, sueño. Consumo de

sustancia.
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Examen mental
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Diagnóstico

Eje I._________________________________________________
Eje II. ________________________________________________
Eje III. _______________________________________________
Eje IV. _______________________________________________
Eje V. _______________________________________________

Observaciones:
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Firma del Psicólogo (a)