SERVICIO DE PSICOLOGÍA

HISTORIA CLINICA
Psic. Verónica Becerra Llamo

I. DATOS DE FILIACION:
 Apellidos y Nombres:_________________________________________________
 Edad:________ Fecha de Nac:__________ Lugar de Nac:___________________
 Estado civil:______________ Grado de instrucción:________________________
 Domicilio:__________________________________________________________
 Religión:________________ Ocupación:_________________________________
 Nº de hermanos: __________ Lugar que ocupa:___________________________
 Teléfono: _____________ E-mail: ______________________________________

II. MOTIVO:
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III. HISTORIA PERSONAL:

 Parto:__________________________________________________________
 Lactancia:_______________________________________________________
 Independencia:___________________________________________________
 Enfermedades:___________________________________________________
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 Accidentes:______________________________________________________
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 Operaciones:_____________________________________________________
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 Escolaridad
 Inicial:__________________________________________________________
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 Primaria:________________________________________________________
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 Secundaria:______________________________________________________
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 Otros:__________________________________________________________
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 Sueño:__________________________________________________________
 Vida Laboral:_____________________________________________________
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 Vida sexual: _____________________________________________________
 Vida familiar :____________________________________________________
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 Reuniones sociales:_______________________________________________
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 Personalidad:____________________________________________________
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 Consumo de drogas, alcohol:________________________________________
 Antecedentes policiales o judiciales:__________________________________
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IV.HISTORIA FAMILIAR:
 Padre:__________________________________________________________
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 Madre:__________________________________________________________
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 Hermanos:______________________________________________________
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 Situación económica:______________________________________________