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N° Ficha:

Ficha clínica Infanto Juvenil

1.- Antecedentes personales:


Nombre: _________________________________________________________________________________________________
Edad:
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Rut:
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Fecha de nacimiento:
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Escolaridad: _____________________________________________________________________________________________
Con quien vive:
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Padre: ______________________________________________ Madre: ____________________________________________
Edades: ________________________________ Actividades:
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Teléfono:
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Correo electrónico:
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Derivado: ________________________________________________________________________________________________

Apoderado: _____________________________________________________________________________________________
Relación:
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Teléfono:
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Correo electrónico:
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2.- Motivo de consulta:
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3.- Genograma:

4.- Historia Clínica/tratamientos anteriores/Enfermedades físicas actuales


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5.- Medicamentos:
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6.- Psiquiatra tratante o derivación psiquiatría:


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7.- Observaciones:
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Psicóloga: _______________________________________
Fecha atención _____________________________________
Firma o timbre:

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