H.CL.

Nº___________
DEPARTAMENTO PSICOLÓGICO FECHA____________

HISTORIA CLINICA

I DATOS GENERALES

Nombres y Apellidos_________________________________________________________
Edad_________________ Sexo________________________________________________
Lugar y Fecha de nacimiento:.__________________________________________________
Lugar entre hrnos _________. Grado de instrucción.________________________________
Ocupación/Grado__________________Domicilio__________________________________
Religión. ________________ _______________________________________________
Estado civil______________ Actualmente vive con:________________________________
Si es casado/a y/o conviviente llenar lo siguiente:
Nombre del/la esposo/sa_________________________________________Edad_________
Grado de Instrucción______________________Ocupación___________________________
Parentesco Institucional_______________________________________________________
Informante_________________________
Evaluador__________________________

EN CASO DE NIÑOS :llenar lo siguientes datos

MADRE:
Nombre____________________________________Edad________________
Grado de Instrucción______________________Ocupación_______________

PADRE:
Nombre____________________________________Edad________________
Grado de instrucción______________________Ocupación_______________

II OBSERVACIONES GENERALES DE CONDUCTA

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III MOTIVO DE CONSULTA

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IV PROBLEMA ACTUAL
a) Tiempo:_________________________________________________________________
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b) Forma de inicio___________________________________________________________
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c) Síntomas principales_______________________________________________________
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d) Relato __________________________________________________________________
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e) Antecedentes clínicos_______________________________________________________
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V HISTORIA PERSONAL

 Embarazo _______________________________________________________________
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 Parto ___________________________________________________________________
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 Control medico____________________________________________________________
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 Alimentación _____________________________________________________________
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 Lenguaje ________________________________________________________________
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 Motricidad _______________________________________________________________
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 Control de esfínteres _______________________________________________________

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 Sueño ___________________________________________________________________
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 Escolaridad ______________________________________________________________
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 Adolescencia y juventud____________________________________________________
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 Hábitos e intereses ________________________________________________________

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 Accidentes y enfermedades __________________________________________________

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 Historia psicosexual _______________________________________________________

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 Historia familiar __________________________________________________________

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 Historia socioeconómica y ocupacional

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VI EXAMEN MENTAL
A. Apreciación general
 Apariencia____________________________________________________________
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 Comportamiento y actividad psicomotriz____________________________________
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 Actitud hacia el examinador_______________________________________________

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B Humor, Afecto y propiedad

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C Lenguaje__________________________________________________________________
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D Alteraciones sensoperceptivas_________________________________________________
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E Pensamiento_______________________________________________________________
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F Sensorio y Cognición
 Alerta y nivel de conciencia
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 Orientación_____________________________________________________________
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 Memoria_______________________________________________________________
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 Concentración y atención__________________________________________________
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 Capacidad de lectura y escritura

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 Habilidad visoespacial
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 Pensamiento abstracto
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 Consolidación de la información y la inteligencia

G Control de impulsos
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H Juicio e Insight
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VII DIAGNÓSTICO PRESUNTIVO Y/O DEFINITIVO CIE 10_____________

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IX DIAGNÓSTICO FUNCIONAL
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X DIAGNÓSTICO MULTIAXIAL
Eje I_______________________________________________________________________:
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Eje II ______________________________________________________________________
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Eje III _____________________________________________________________________

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Eje IV _____________________________________________________________________
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Eje V _____________________________________________________________________
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XI. EVOLUCION:

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H.CL. Nº___________
DEPARTAMENTO PSICOLÓGICO FECHA____________

FICHA PSICOLOGICA DEL PACIENTE HOSPITALIZADO

I DATOS GENERALES
CAMA_______
Nombres y apellidos_____________________________________________
Edad_________________ sexo____________________________________
Lugar y Fecha de nacimiento______________________________________
Lugar entre hrnos _________. Grado de instrucción.___________________
Ocupación/Grado__________________Domicilio_____________________
Religión. ________________ __________________________________
Estado civil_________________ Informante_________________________
Evaluador_____________________________________________________
Servicio_____________ tipo de ingreso__________________________
Parentesco Institucional__________________________________________
Red de apoyo y soporte emocional__________________________________
Que tipo de visitas recibe o recibió__________________________________
Nº de visitas psicológicas_________________________________________

Si es casado/a y/o conviviente llenar lo siguiente:

Nombre del/la esposo/sa_________________________________________Edad__________
Grado de Instrucción______________________Ocupación___________________________
En caso de niños tomar los siguientes datos:

MADRE:
Nombre____________________________________Edad y FN________________________
Grado de Instrucción__________________________Ocupación________________________

PADRE:
Nombre____________________________________Edad y FN________________________
Grado de instrucción__________________________Ocupación________________________

II OBSERVACIONES GENERALES DE CONDUCTA

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III MOTIVO DE INTERNAMIENTO

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En Caso de una Intervención

1- ESTADO MENTAL ANTES DE LA INTERVENCION
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2- ESTADO MENTAL DESPUES DE LA INTERVENCION

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IV PROBLEMA PSICOLOGICO ACTUAL

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V OTRAS OBSERVACIONES
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VI RESULTADOS DEL MINIMENTAL DE FOLSTEIN

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VII RECOMENDACIONES
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