I DATOS GENERALES:

Nombre completo:
________________________________________________________________

Sexo:__________________

Fecha de nacimiento ________________________Edad____________

Estado civil: _____________________

Nivel de escolaridad:_____________________________________________

Profesión:_______________________________________________________

Ocupación:______________________________________________________

Religión:________________________________________________________

Dirección:_______________________________________________________

Teléfono de casa:_______________________________
celular:____________________________

Referido por:______________________________________________________

Fecha de inicio del proceso:__________________________________________

II MOTIVO DE CONSULTA:__________________________________________

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III HISTORIA ACTUAL DEL PROBLEMA:_________________________________

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IV ANTECEDENTES:________________________________________________

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V. TOXICOMANÍAS _________________________________________________
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VI HÁBITOS: _____________________________________________________

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VII PATRÓN DE SUEÑO______________________________________________

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VIII PERSONALIDAD PREMÓRBIDA: ___________________________________

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IX HISTORIA PERSONAL: ____________________________________________

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Historia prenatal:___________________________________________________

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Nacimiento:________________________________________________________
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Esfínteres:_________________________________________________________
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Evolución del lenguaje:_______________________________________________

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Desenvolvimiento escolar:_____________________________________________

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Desenvolvimiento social:______________________________________________

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Adolescencia:_______________________________________________________
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Adultez:___________________________________________________________
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Historia psicosexual y vida marital:_____________________________________

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Historia médca______________________________________________________

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Antecedentes de desórdenes emocionales o mentales:______________________

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HISTORIA FAMILIAR
Antecedentes familiares:_____________________________________________

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Genograma

X EXAMEN DEL ESTADO MENTAL:

● Apariencia y actitud ____________________________________________

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● Orientación y conciencia ________________________________________
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● Lenguaje_____________________________________________________
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● Pensamiento__________________________________________________
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● Sensopercepción______________________________________________
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● Estado de ánimo_______________________________________________
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● Memoria_____________________________________________________
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● Insight_______________________________________________________
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● Juicio de realidad:_____________________________________________
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● Inteligencia:__________________________________________________
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XI. RESULTADO DE PRUEBAS APLICADAS:

XII OTROS ESTUDIOS DIAGNÓSTICOS: _______________________________

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XIII IMPRESIÓN DIAGNÓSTICA: _______________________________________

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XIV DIAGNÓSTICO:_________________________________________________

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XV DIAGNÓSTICO DIFERENCIAL:____________________________________

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XVI COMORBILIDAD: _______________________________________________

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XVII PRONÓSTICO: _________________________________________________

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XVIII RECOMENDACIONES: __________________________________________

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XIX CONCLUSIONES: ______________________________________________

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XX FIRMA DEL EVALUADOR: ______________________________________