Historial Clínico

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Datos generales

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Domicilio___________________________Ocupación________________________
Estado civil_________________________Religión__________________________
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En caso de emergencia comunicarse_____________________________________
Fecha de la evaluación: _______________________________________________
Fecha del informe: __________________________________________________
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Motivo de la consulta

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 Anamnesis personal patológica

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Antecedentes del paciente

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Antecedentes familiares.

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Desarrollo psicomotriz en mi niñez.

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 Exploración Física
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Exploración Neuropsicológica.
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Personalidad

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Perfil social

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Datos relevantes sobre la familia del paciente.

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Actividades ludicas de la vida diaria.
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Pruebas aplicadas.

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Examen mental

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Apariencia general y actitud

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Estado de conciencia.

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Estado de ánimo

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Actividad motora actual.

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Asociación y flujo de ideas y características del lenguaje

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Diagnóstico.

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Pronostico

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Plan de abordaje psicológico.

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Técnicas psicológicas utilizadas

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Objetivo del tratamiento y técnicas a emplear para conseguirlos.

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Tratamiento

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Recomendaciones

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Calificado por: ___________________________________