FORMATO DE HISTORIA CLINICA PSICOLÓGICA

FECHA: __________________________
HORA DE INICIO: _______________
HORA FINALIZACION: _________

I. DATOS PERSONALES
NOMRE Y APELLIDOS COMPLETOS: _______________________________________ EDAD: ________ SEXO: _________
LUGAR Y FECHA DE NACIMIENTO: ________________________________________ ESTADO CIVIL: _______________________
GRADO DE ESCOLARIDAD: _________________________________________________ OCUPACION: _________________________
DIRECCION RESIDENCIA: ___________________________________________________ TELEFONOS: _________________________
ESTRATO: ________________

HA RECIBIDO ATENCION PSICOLOGICA SI____ NO____

CUAL FUE EL MOTIVO: ___________________________________________________________________________________________________
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HACE CUANTO: ___________________________________________________________________________________________________________
CONTINUO CON LA AYUDA PSICOLOGIA SI___ NO___ PORQUE _______________________________________________________
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II. MOTIVO DE CONSULTA

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III. DESCRIPCION DEL PACIENTE

-FACTORES DESENCADENANTE: _________________________________________________________________
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-ESTADO SOMÁ TICO ACTUAL Y PASADO. HÁ BITOS DE SALUD Y DIETA: _______________________
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-ANTECEDENTES DE TRASTORNOS PSIQUICOS: _________________________________________________
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IV. ANTECENDENTES RELEVANTES FAMILIARES

-Composició n nú cleo familiar: (Sexo, edad, parentesco, profesió n)
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-Relació n interpersonal con su nú cleo familiar:

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-Trastornos somá ticos actuales y pasados relevantes:

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V. VALORACION DELSOPORTE SOCIO FAMILIAR

-Reacció n y/o apoyo familiar al trastorno actual
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-Calidad y cantidad de relaciones sociales
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-Problemas y satisfacció n conyugal o de pareja
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-Problemas y satisfacció n laboral – estudios
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VI. PERFIL MULTI MODAL

A. Área cognitiva:
-Preocupació n má s frecuentes y molestas
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-Ideació n suicida. Actitud ante la vida. Ganas de vivir y razones de ello
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-Trastornos del pensamiento y de otras actividades mentales (alucinaciones, delirios)
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Autovaloración personal:
-Aspectos positivos de sí mismo
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-Aspectos negativos de sí mismo
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-Satisfacció n con la imagen/ aspecto corporal
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-Sueñ os y fantasías má s frecuentes
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-Expectativas del tratamiento (a que causa le atribuye su malestar y cuá l cree que es la
intervenció n a desarrollar y el papel que le corresponde en la misma)
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B. Área afectiva:
- Estado de á nimo actual má s frecuente
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-Principales temores actuales

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-Principales desencadenantes de IRA actuales

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-Situaciones, actividades y personas con las que se siente tranquilo y má s alterado

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-Como suele expresar sus emociones má s intensas (amor, ira, tristeza, etc.) y a quien
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C. Área somática:
-Problemas de há bitos de salud: ejercicios, dieta, peso, tabaco, alcohol y otras drogas
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-Enfermedades actuales: diagnó stico y tratamiento en curso

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-Sensaciones y molestias corporales

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-Satisfacció n y problemas sexuales

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D. Área interpersonal:
-Relaciones, problemas y satisfacció n laboral/ estudios
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-Relaciones familiares: problemas y apoyo de quien- como
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-Relaciones de pareja: problemas y á reas de satisfacció n
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-Relaciones sociales: cantidad/ calidad de amistades
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E. Área conductual:
-Có mo afronta sus dificultades motivos de consulta: Que hace y evita al respecto.
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-Há bitos que desearía aumentar

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-Há bitos que desearía disminuir
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Actividades má s gratificantes reforzantes y desagradables, aversivas actualmente
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 FORMATO DE HISTORIA CLINICA PSICOLÓGICA

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VII. PRUEBA PSICOLOGICA Y ANÁLISIS DE RESULTADOS:

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VIII. DIAGNOSTICO:
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IX. OBJETIVOS TERAPEUTICOS

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PSICÓLOGA:__________________________________________