ENTREVISTA PSICOLÓGICA

Fecha: _________________________

DATOS GENERALES.

Nombre Completo: ________________________________________________________________

Fecha de Nacimiento: ______________________________________________________________

Lugar de Nacimiento: ______________________________________________________________

Edad: _____________ Sexo: ________________

Dirección: _______________________________________ Teléfono: ________________________

Grado de escolaridad: ______________________________________________________________

Ocupación: ______________________________________________________________________

Estado Civil: ______________________________________________________________________

Pasatiempos: _____________________________________________________________________

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¿Practica algún deporte? Si: ____ / No: _____ ¿Cuáles? __________________________________

Fuma: Sí: ___ / No: ____ Si responde sí, cuántos al día: ___________________________________

Ingiere bebidas alcohólicas: Sí: ___ / No: ___ Especifique: _________________________________

Padecimiento de alguna enfermedad: _________________________________________________

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¿Toma algún tipo de medicamento? Sí: ___ / No: ___ Especifique: __________________________

MOTIVO DE CONSULTA Y EXPLORACION DEL CUADRO CLÍNICO:

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AV. COLEGIO MILITAR #50 INTERIOR 6, GPE, ZACAETCAS. ADMIN

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HISTORIA PERSONAL

Antecedentes prenatales:

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Antecedentes perinatales:
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Antecedentes postnatales:

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Ámbito social:

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Ámbito escolar:

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Ámbito afectivo:

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HISTORIA FAMILIAR.

Datos de la familia (quiénes la conforman, cuantos son, edad, ocupaciones, etc.):

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AV. COLEGIO MILITAR #50 INTERIOR 6, GPE, ZACAETCAS. ADMIN
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Relación con el padre:

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Relación con la madre:

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Relación con los hermanos y hermanas:

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Relación con la pareja:

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Relación con los hijos e hijas:

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Observaciones.

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AV. COLEGIO MILITAR #50 INTERIOR 6, GPE, ZACAETCAS. ADMIN
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Plan de acción.

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AV. COLEGIO MILITAR #50 INTERIOR 6, GPE, ZACAETCAS. ADMIN