ANAMNESIS PSICOLOGICA

I. DATOS DE AFILIACIÓN
1. Nombre:
2. Edad : ……………………………………………………………………………………………….
3. Sexo : ……………………………………………………………………………………………….
4. Fecha y lugar de nacimiento: …………………………………………………………………….
5. Grado de instrucción : …………………………………………………………………………….
6. Ocupación: ……………………………………………………………………………………………….
7. Estado civil: ……………………………………… Religión: ……………………………………..
8. Procedencia: …………………………………………………………………………………………….
9. Centro de estudios y/o trabajo : …………………………………………………………………….
10. Domicilio actual:…………………………………………………………..Tfno.……………………..
11. Referente (enviado por):……………………………………………………………………………….
12. Lugar donde se realiza la entrevista :
……………………………………………………………….
13. Fecha de la entrevista:………………………………………………………………………………….
14. Informante (es) …………………………………………Parentesco………………………….
15. Fechas de estudio :………………………………………………………………………………….
16. Examinador o entrevistador :………………………………………………………………….

II. MOTIVO DE LA CONSULTA

--------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------
III. PROBLEMA ACTUAL
--------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------

IV. HISTORIA PERSONAL

---------------------------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------------------

V. HISTORIA FAMILIAR
 --------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------

VI. HISTORIA SOCIOECONOMICA Y OCUPACIONAL

--------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------

VII. RASGOS Y CARACTERÍSTICAS DE PERSONALIDAD

--------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------

FIRMA DEL EXAMINADOR