FECHA:_______________ N° DE DNI:__________________________

FICHA DE EVALUACIÓN PSICOLÓGICA INDIVIDUAL

1. DATOS DE FILIACIÓN
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Nombre y Apellido
: _
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Edad
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Fecha de Nacimiento _
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Grado de Instrucción : _
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Estado Civil : _
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Ocupación : _
Miembros de la : 1-_______________________________________
familia : 2-_______________________________________
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: 5-_______________________________________
: 6-_______________________________________
: 7-_______________________________________
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Fecha de Entrevista : _
N° de Celular : ________________________________________
_
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Psicoterapeuta : _

OBSERVACIONES GENERALES:
Paciente de ____ años. Se encontró lucido (__), orientado en tiempo (__), espacio (__) y persona (__).
Hace uso de un lenguaje claro (__), coherente (__) y funcional (__) de acuerdo al contexto con un tono de
voz adecuado. Durante la evaluación se mostró
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T°:__________ P/A:_________ SO2:______ TALLA:_______ PESO:_______ PULSO X1:_______

2. MOTIVO DE CONSULTA:
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3. ANTECEDENTES:
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4. EVALUACION:
Paciente de ___ años proviene de una familia ____________ con comportamientos
___________________________________________________ Presenta síntomas:
Emocionales___________________________________________________________________________
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fisiológicos:____________________________________________________________________________
________________________________________________Cognitivos:____________________________
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__________Conductuales_________________________________________________________________
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Factores de Riesgos: __________________________________________________
__________________________________________________________________Antecedentes de
Riesgos: _____________________________________________
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5. DX PRESUNTIVO:
FECHA:_______________ N° DE DNI:__________________________
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6. PLAN DE TRATAMIENTO (xs):

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