HISTORIA CLÍNICA ADOLESCENTES

 DATOS DE IDENTIFICACIÓN PI FECHA: ___________________

NOMBRE: __________________________________________________________EDAD: ________

SEXO: _______ FECHA DE NACIMIENTO: ________________ DOMICILIO: _____________________

_______________________________________ TELÉFONO: _______________________________

RELIGIÓN: ______________________________ ESCOLARIDAD: ____________________________

 DATOS FAMILIARES

NOMBRE DE LA MADRE: ______________________________________________EDAD: ________

DOMICILIO: _________________________________________ TELÉFONO: ___________________

OCUPACIÓN: _________________________________.

NOMBRE DEL PADRE: ______________________________________________EDAD: __________

DOMICILIO: _________________________________________ TELÉFONO: ___________________

OCUPACIÓN: _________________________________.

NOMBRE Y EDAD DE HERMANOS: ____________________________________________________

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 PERSONA QUE SOLICITA EL SERVICIO

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 MOTIVO DE CONSULTA

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 CRONOLOGÍA Y SINTOMATOLOGÍA (INICIO, INTENSIDAD, DURACIÓN, FRECUENCIA, ANTECEDENTES)

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  FAMILIOGRAMA

 HISTORIA DE EVOLUCIÓN

EMBARAZO, PARTO, CLIMA EMOCIONAL DE LA FAMILIA: __________________________________

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NIÑEZ (ENFERMEDADES, CIRUGÍAS, AVE): ___________________________________________________

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ÁREA ESCOLAR Y EDUCATIVA (INTEGRACIÓN, SATISFACCIÓN, RENDIMIENTO ACADÉMICO): _________________

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ÁREA SOCIAL: ____________________________________________________________________

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SEXUALIDAD: _____________________________________________________________________

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 ALIMENTACIÓN: ____________________________________________________________

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 ACTIVIDAD FÍSICA: __________________________________________________________

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 CALIDAD Y HABITOS DE SUEÑO: _______________________________________________

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 USO DE REDES SOCIALES Y DISPOSITIVOS ELECTRÓNICOS: __________________________

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 FACTORES, CONDUCTAS Y/O SITUACIONES DE RIESGO: _____________________________

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 FACTORES, CONDUCTAS Y/O SITUACIONES PROTECTORAS: _________________________

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 OBSERVACIONES: ___________________________________________________________

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 IMPRESIÓN DIAGNÓSTICA: ___________________________________________________

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 ASPECTOS A TRABAJAR: ______________________________________________________

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 OBJETIVOS DEL PI: __________________________________________________________

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PROXIMA CITA: ___________________________________________________________________

EVOLUCIÓN: