HISTORIA CLINICA - ADULTOS

FECHA: ______________________

PSICOLOGO: _________________________________________________ N° de Historia: ___________________

1.- DATOS DE IDENTFCACION

Nombre y Apellido: _________________________________________________________________________________

Lugar y Fecha de nacimiento: ________________________________________ C. I.:_____________________________
Edad Cronológica:______________________ Sexo: ________________ Escolaridad ____________________________
Nombre y Dirección de la Escuela: _____________________________________________________________________
___________________Grado__________________Seccion:__________________ Religión:_______________________

2.- DATOS DE IDENTFCACION DEL REPRESENTANTE (Facilitador de la información, parentesco con el

paciente)

Nombre y Apellido: _________________________________________________________________________________

Lugar y Fecha de nacimiento:__________________________________________________________________________
Edad Cronológica:______________________ Sexo: ______________________ C. I.:____________________________
Grado de escolaridad:_____________________________Ocupacion:__________________________________________
Nombre y Dirección de Empleo:________________________________________________________________________
Dirección de habitación:______________________________________________________________________________
Teléfonos:___________________________________________________ Religión:______________________________

3.-FUENTE DE REFERENCIA, CONTACTOS PREVIOS CON INSTITUCIONES O PROFECIONALES

(Nombre de la institución y profesionales, fecha, tratamiento, motivo de egreso, resultado de tratamiento)
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4.-MOTIVO DE CONSULTA
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5.-SITUACIÓN ACTUAL
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6.-GENITOGRAMA Y DINAMICA FAMILIAR
(nombres, genero, edad, ocupación de cada uno de los miembros, tipo de relación, miembros que viven juntos)
7.- ANTECEDENTES PERSONALES:
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8.-ANTECEDENTES FAMILIARES:
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9.-AREAS DE EXPLORACIÓN:

Académica (inicio, adaptación, rendimiento, relación con pares y maestros, actividades extracurriculares)
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Laboral (inicio, adaptación, estabilidad, sueldo y distribución, relación con subordinados/pares/jefes)

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Sexual (edad desarrollo, primera masturbación/relación sexual, identidad, orientación, violencia)

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Social (amigos, comunidad, uso del tiempo libre, rutina diaria, distracciones, actividades domesticas)
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Afectiva (reconocimiento y manejo de emociones y sentimientos)

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10.-HÁBITOS PSICOBIOLOGICOS (Ingesta de alcohol y/o consumo de sustancias , rutina diaria, juegos,
distracciones, tiempo libre, hábitos en general):
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Hábitos de alimentación:
Desayuna en casa: ______ Tiene buen apetito: ______ Falta de apetito: _____ Glotonería: _______ Pica:______
Alimentos que no puede consumir por prescripción médica:
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Hábitos de Sueño:
Hora de acostarse: _________ Levantarse: _________ Duerme solo: _________
Descripción del sueño:
Tranquilo: _____________ Agitado: ____________ Insomnio:__________ Se despierta con frecuencia:___________
Teme a la oscuridad:__________ Bruxismo:__________ Terrores nocturnos:____________ pesadillas____________

Se queja a presenta:
Dolor de Cabeza:_______ Mareos:_______ Se queja sin razón:________ Diarrea:________ Constipación:________
Caída del cabello:____________ Curiosidad sexual:____________________ Dolor de estomago:_________________
Teme a no tener amigos:__________ Acepta su cuerpo:______________ Usa su tiempo libre:___________________

11.- EXAMEN MENTAL

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12.- IMPRESIÓN DIAGNOSTICA:

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13.- PLAN DE TRATAMIENTO:

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14.- EVOLUCIÓN:
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15.- INSTRUMENTOS APLICADOS:

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