FORMULARIO HISTORIA CLÍNICA ADULTOS

Datos de identificación:

Nombre y apellido del paciente: _______________________________________________

Lugar y fecha de nacimiento: _________________________________________________
Edad: ___________________________sexo: __________________
Estudios: ________________________Ocupación actual: ________________
Dirección de Residencia: _____________________________________________________
___________________________________________Teléfono: _____________________
Dirección de empleo: _______________________________________________________
____________________________________________Teléfono: _____________________
Religión: ____________________________ Supervisor: ___________________
Referido por: _____________________________ Fecha de consulta: ______/_____/_____

Motivo de consulta
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Situación actual del paciente

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Antecedentes personales
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Antecedentes médicos
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Biografía
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Historia escolar
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Historia de relaciones interpersonales

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Historia conyugal
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Historia laboral
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Historia familiar y su dinámica

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Historia de abusos, traumas, negligencia. Perdidas.

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Hábitos psicobiológicos. Alimentación, eliminación, sueño. Consumo de sustancia.

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Examen mental
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Diagnóstico
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Observaciones:
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Firma del Psicólogo (a)