Historia Clínica

Nombre: ________________________________________Edad:_______________

Lugar y Fecha de Nacimiento: __________________________________________

Dirección: _______________________________Estado civil: ________________

Escolaridad:__________________ Oficio:______________________

Religión:_________________Fecha:__________

Motivo de consulta

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Estructura Familiar Primaria

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Estructura Familiar Secundaria

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Historia Escolar

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Historia Laboral

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Adicciones y/o Toxiconomia

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Historia de Salud

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Socialización

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Área Sexual

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Examen del Paciente

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"Dar produce más felicidad que recibir, no porque sea una privación, sino porque en el acto
de dar está la expresión de mi vitalidad!" (Erich Fromm).

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Estudiante en Psicología María de Jesús Rebollar
Gómez