FORMATO DE HISTORIA CLÍNICA

(Esta información deberá ser llenada principalmente por datos obtenidos mediante la entrevista PUEDE apoyarse de
instrumentos (test) justificando su uso y reportando los resultados obtenidos).
l. DATOS PERSONALES

N.° historia: ____________ Fecha: _____________

Nombres: *________________________________________ Apellidos: ______________________________
Documento de identidad: T.I.___ C.C.___ No. _______________________________
Edad: * ______________ Sexo: *__________ Estado civil:* ______________ Religión:
*_________________
Lugar y fecha de nacimiento: *________________________________________________________________
Escolaridad: * _______________________ Ocupación: *_______________
Dirección actual: ________________________________________________________________________
Teléfono: _____________
Dirección de la familia: _____________________________________ Ciudad: *____________________
Teléfono: _______________

*Ha recibido algún tipo de tratamiento psicológico o psiquiátrico: SÍ ( ) NO ( )

*Explique el motivo:
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*Nombre y cédula profesional del entrevistador: ___________________________________________

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_

*La información de la ficha de identificación con asterisco es obligatoria

NOTA: PUEDE AGREGAR DATOS SI LO CONSIDERA NECESARIO.

ll. MOTIVO DE CONSULTA:

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lll. DEFINICIÓN DEL PROBLEMA:

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 INICIO:
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 EVOLUCIÓN:
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 CAUSAS:
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 ACCIONES REALIZADAS EN BUSCA DE SOLUCIÓN:

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 IMPLICACIONES: (a nivel familiar, social, académico, etc.):

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lV. ESTRUCTURA Y FUNCIONALIDAD FAMILIAR:

 FAMILIOGRAMA: (ANEXO)

MIEMBRO PARENTESCO EDAD ESCOLARIDAD OCUPACIÓN

 VÍNCULOS AFECTIVOS, CONFLICTIVOS Y REDES DE COMUNICACIÓN:

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V. HISTORIA PERSONAL:

 INFANCIA:
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 ADOLESCENCIA:
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 ADULTEZ:
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VI. HISTORIA ESCOLAR:

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VII. OBSERVACIONES: (descripción física, lenguaje no verbal, actitud, etc.)

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VIII. DIMENSIONES:

 COMPORTAMENTAL: ______________________________________________________________________________
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 AFECTIVA: ________________________________________________________________________________________
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 SOMÁTICA: ________________________________________________________________________________________
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 COGNITIVA: _______________________________________________________________________________________
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 SOCIAL: __________________________________________________________________________________________
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IX. PRUEBA Y ANÁLISIS DE RESULTADOS:

 PERSONALIDAD: ___________________________________________________________________________________
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 INTELIGENCIA: ____________________________________________________________________________________
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 HABILIDADES: _____________________________________________________________________________________
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 OTRAS: ___________________________________________________________________________________________
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X. IMPRESIÓN DIAGNÓSTICA:
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XI. TRATAMIENTO A SEGUIR:
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EVOLUCIÓN

Sesión n. ° ________ Fecha: ______________________

Objetivo: __________________________________________________________________________________________
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Descripción: _______________________________________________________________________________________
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Sesión n. ° ________ Fecha: ______________________

Objetivo: __________________________________________________________________________________________
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Descripción: _______________________________________________________________________________________
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Sesión n. ° ________ Fecha: ______________________

Objetivo: __________________________________________________________________________________________
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Descripción: _______________________________________________________________________________________
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Sesión n.° ________ Fecha: ______________________

Objetivo: __________________________________________________________________________________________
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Descripción: _______________________________________________________________________________________
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Sesión n.° ________ Fecha: ______________________

Objetivo: __________________________________________________________________________________________
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Descripción: _______________________________________________________________________________________
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Sesión n.° ________ Fecha: ______________________

Objetivo: __________________________________________________________________________________________
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Descripción: _______________________________________________________________________________________
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EVALUACIÓN REALIZADA POR: ____________________________________