Psychological Clinical History Format

Psychology Area

Clinical File

Name:
_____________________________________________________________________
Address:
_____________________________________________________________________
Place and date of birth:
_____________________________________________________________________
Current age:
____________________________Sex:____________________________________
Marital status: ____________________________Religion:
_______________________
Profession:
______________________________Occupation:_____________________
Name of spouse____________________________________________________
Race:
__________________________Email______________________________________
Consultation date:____________________phone:____________________

REASON FOR CONSULTATION:

_____________________________________________________________________

_____________________________________________________________________
_____________________________________________________________________

CURRENT PROBLEM:

_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
________________

HISTORY OF THE CURRENT ILLNESS:

_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
___________________________

BACKGROUND:

to. Hereditary:

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

b. Congenital:

_____________________________________________________________________
_____________________________________________________________________

_____________________________________________________________________

c. Personal pathological (from childhood):

_____________________________________________________________________
_____________________________________________________________________

_____________________________________________________________________

d. Physiological (nutritional, elimination):

_____________________________________________________________________
_____________________________________________________________________
____________________________________________________________________

and. Gynecological (women) sexual maturity (both sexes):

_____________________________________________________________________
_____________________________________________________________________

_____________________________________________________________________

F. Surgical:

_____________________________________________________________________
_____________________________________________________________________

_____________________________________________________________________

g. Habits and customs (personal)

_____________________________________________________________________
_____________________________________________________________________

_____________________________________________________________________

h. Educational (last grade completed:

_____________________________________________________________________
_____________________________________________________________________

_____________________________________________________________________

Yo. Work (places where you have worked, including the last job you did):

_____________________________________________________________________
_____________________________________________________________________

_____________________________________________________________________

j. Sexual (menarche, masturbation):

_____________________________________________________________________
_____________________________________________________________________

_____________________________________________________________________
k. Spousal (as spouse, as parent):

_____________________________________________________________________
_____________________________________________________________________

_____________________________________________________________________

l. Recreational, sporting and cultural:

_____________________________________________________________________
_____________________________________________________________________
____________________________________________________________________

m. Psychopathological:

_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

FAMILY HISTORY:

Marital status of parents: _________________________________

Father's Information Mother's Information

Age at marriage or union Age at marriage or union

Current age Current age

Occupation Occupation

Scholarship Scholarship

Place of birth Place of birth

_____Number of years living together

_____Number of years apart
_____Number of children
_____How are the relationships between them?
1. Hello good
2. Regular
3. Bad
Pathological History of the Parents:

Use: 0 = They are not or are ignored 1 = The father is 2 = The mother is 3 = Both
are
_____Parents who are neurotic or have apparent character or personality alterations
_____Alcoholic parents
_____Parents with psychophysiological problems
_____Psychotic parents
_____Epileptic parents
_____Parents with neurological problems
_____Parental aggression towards children
_____Mental or behavioral alterations
_____Parents who are emotionally distant from their children
_____Parents over protectors
_____Parents over 65 years of age
_____Deceased parents
_____If yes, age of the subject when the father died

Siblings' Pathological History:

Sibling Data: Write down from oldest to youngest

1 2 3 4 5 6 7

Age:

Sex:

Occupation
:

For the following questions, use:

0 = They are not or it is ignored
1 = They are (write down number of siblings with a problem)

_____Neurotic siblings or siblings with apparent character or personality alterations

_____Alcoholic brothers
_____Siblings with psychophysiological problems
_____Psychotic brothers
_____Epileptic Brothers
_____Siblings with neurological problems
_____Habitual aggressive siblings
_____Siblings with a history of sob spasm
_____Siblings with mental retardation
_____Brothers in constant problem with subject
_____Siblings with deafness problem
_____Siblings with visual problems and who wear glasses
_____Brothers who already work
_____Brothers who study
_____Siblings who dropped out of school and do not work
_____Siblings who use drugs
_____Siblings who have frequent conflicts with parents and siblings
_____Brothers who have had problems with the authorities
_____Siblings with language problems

Do you have friends with the neighbors?:

________________________________________
Who do you mainly like to talk to?: ________________________________
Do you prefer friends of the same or different
sex?:_______________________________
Other family members living in the
home?:____________________________________
Strangers living in the home?: _________________________________________

OBSERVATIONS:

_____________________________________________________________________
_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________
_____________________________________________________________________

DIAGNOSIS OR CLINICAL IMPRESSION:

_____________________________________________________________________
_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

THERAPY PLAN:

_____________________________________________________________________
_____________________________________________________________________

_____________________________________________________________________
_____________________________________________________________________

_____________________________________________________________________

PSYCHOTHERAPY:

_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
________________

______________________________________
Signature