historia clinica psicologica

fecha de evaluacon________

terapeuta__________

I. DATOS DE IDENTIFICACION

nombre y apellido :____________________________________

c.i:________________edad:_____estado civil:_____________

lugar y fecha de nacimiento:____________________________

sexo: F( ) M ( )

profesion /oficio:_____________________________________

religion:__________

nivel de instruccion:__________________________________

direccion:___________________________________________

_________________________________telefono:___________

referido:_____________________________________________

II. MOTIVO DE CONSULTA

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III. GENOGRAMA

IV. SITUACCION ACTUAL

familiar
:________________________________________________________
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social:___________________________________________________
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laboral/educativa
:________________________________________________________
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V. ANTECEDENTES PSIQUIATRICOS :

Si ( ) No ( ) Fecha_______________ diagnostico
:________________________________________________________
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VI. ANTECEDENTES PERSONALES (MEDICO):

Enfermedad__________________________________________
parentesco _____________edad_____

Enfermedad__________________________________________
parentesco _____________edad_____

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VII. HISTORIA DE VIDA

area
familiar:_________________________________________________
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area
educativa:_______________________________________________
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area
laboral:__________________________________________________
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area
social:___________________________________________________
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sexualidad y pareja
:________________________________________________________
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VIII. EXAMEN MENTAL

conciencia:

lucidez ___somnolencia___obnobulacion___

atencion:

euprosexia___hipoprosexia___hiperprosexia___ selectiva___

orientacion :

tiempo___ espacio___persona ___

memoria:

retrograda__anterograda__de fijacion____de evocacion___

afectividad:

eutimia___hipotimia___hipertimia___hacia el polo___

lenguaje:

intensidad: normal:___aumento:___disminucion___

ritmo: eulalico___bradilalico___taquilalico___

pensamiento:

ideas dominantes:_______________________

normopsiquico____delirios(celos,persecusion,grandeza)________

fuga de ideas:________ pensamiento intuitivo:_____________

pensamiento logico :_________________

sensopercepcion:

conservada________ilusion________alucinacion_____________

psicomotricidad:

(movimientos involuntarios) si ( ) no ( )

impresion del funcionamiento inteletual

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conciencia de enfermedad :_____________________________

observaciones
________________________________________________________
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IX. HABITOS

sueño: ______________________________________________

alimentacion: _______________________________________

aseo:_ ____________________________________________

rutina:_ ____________________________________________

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X. IMPRESION GENERAL

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XI. IMPRESION DIAGNOSTICA

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XII. PLAN DE TRATAMIENTO

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