FICHA DIAGNOSTICO PATRON DE CONSUMO

I. IDENTIFICACION

Nombre _________________________________________________________ Edad __________

Estado civil ________________________ Hijos _____________________________________

Escolaridad ______________________________________________________________________

Oficio ___________________________________________________________________________

II. HISTORIA DE CONSUMO

Sustancia Edad Tiempo Vías de Efectos Frecuencia Frecuencia

de de administración buscados en libertad en
inicio consumo reclusión

Motivación para consumir

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Contexto en que se da el consumo en el último año

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

Desencadenantes para la dependencia

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

Financiamiento

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

Intentos de abstinencia /tratamientos anteriores

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Familia y consumo de drogas

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

Consumo de drogas y grupo de pares

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

Conclusión
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

_______________________________
Nombre y Firma Profesional

Fecha_______________________________