LOGO PÁGINA 1

NOMBRE DE DE LA EMPRESA DE: 3

HISTORIA CLINICA PSICOLOGIA VERSIÓN:

Fecha Sesión Inicial: ___________ No. historia Clínica: ___________

A. DATOS PERSONALES

NOMBRE COMPLETO: _____________________________________________________________ Edad: _________

Tipo de Documento: RC____ TI____ CC____ No. de Documento: ___________________________ Genero: M__ F__
Fecha de Nacimiento: __________________ Lugar: ___________________________ Estado Civil: _______________
Dirección de Residencia: ______________________________ Ciudad: _______________ Teléfono: ________________
Programa Académico (UTS): T - P____________________________________________ Semestre: ________________
Entidad donde labora: ___________________________ Dirección: __________________ Teléfono: ________________
e-mail: _______________________________________

B. DATOS FAMILIARES

PARENTESCO NOMBRES Y APELLIDOS EDAD

PADRE: ___________________________________________________________ ____________
MADRE: ___________________________________________________________ ____________
HERMANOS: ___________________________________________________________ ____________
___________________________________________________________ ____________
___________________________________________________________ ____________
___________________________________________________________ ____________
___________________________________________________________ ____________
PAREJA ACTUAL: ___________________________________________________________ ____________
HIJOS: ___________________________________________________________ ____________
___________________________________________________________ ____________
___________________________________________________________ ____________
___________________________________________________________ ____________
OTROS: ___________________________________________________________ ____________
___________________________________________________________ ____________

C. MOTIVO DE CONSULTA:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

D. FACTORES DESENCADENANTES DEL EPISODIO ACTUAL:

________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
 LOGO PÁGINA 2
NOMBRE DE DE LA EMPRESA DE: 3

HISTORIA CLINICA PSICOLOGIA VERSIÓN:

E. DINAMICA FAMILIAR:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

F. GENOGRAMA:

G. ANTECEDENTES PERSONALES:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

G. ANTECEDENTES FAMILIARES:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

H. AREAS DE AJUSTE:

 FAMILIAR:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

 AFECTIVA:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
 LOGO PÁGINA 3
NOMBRE DE DE LA EMPRESA DE: 3

HISTORIA CLINICA PSICOLOGIA VERSIÓN:

 SOCIAL:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________

 ACADEMICA:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________

I. IMPRESIÓN DIAGNOSTICA:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

J. PLAN DE TRABAJO:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

K. OBSERVACIONES:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

___________________________________________
Psicólogo(a): _______________________________
Tarjeta Profesional No: _______________________