Claudia Valadez Ledesma

Teora y tcnica de la entrevista

FORMATO DE HISTORIA CLNICA

FECHA:___________________________
I.

Datos personales

Nombre:____________________________________________
Edad:_______________
Fecha y lugar de nacimiento: _______________________________________________
Estado Civil: ___________________
Direccin:
Calle/numero
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Colonia___________________________________________________
C.P_______________
Ciudad____________________________________________________
Telfonos:
Casa:_______________________________
Celular:______________________________
Referencia: ___________________________
Email: ________________________________
Ocupacin:____________________________
Religin:______________________________
II.
Descripcin del paciente
1. Caractersticas fsicas:
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Lic. Psicologa Educativa
Universidad Mixta Sabatina UII

Claudia Valadez Ledesma

Teora y tcnica de la entrevista

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2.

Estado de higiene y arreglo personal:

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3.

Lenguaje corporal

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4.

Actitud haca el entrevistador

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III.
1.

Motivo de la consulta
Problema actual: Por qu decidi asistir a terapia?

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2.

Inicio y sntomas:

Factores que desencadenaron el problema

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Lic. Psicologa Educativa
Universidad Mixta Sabatina UII

Claudia Valadez Ledesma

Teora y tcnica de la entrevista

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Cundo comenz el problema?
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Con qu frecuencia sucede este sentimiento, evento o problema?
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Cunto tiempo dura o permanece el malestar o problema?
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3.

Qu cambios ha notado desde entonces?

Salud fsica:
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Familia:
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Trabajo:
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Lic. Psicologa Educativa
Universidad Mixta Sabatina UII

Claudia Valadez Ledesma

Teora y tcnica de la entrevista

Amistades:
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Pareja:
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Escuela:
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4.

Cmo describira su personalidad?

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5.

Por qu solicitar terapia ahora?

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6.

Para qu cree que le servir asistir a consulta?

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Lic. Psicologa Educativa

Universidad Mixta Sabatina UII

Claudia Valadez Ledesma

Teora y tcnica de la entrevista

7.

Referencia/Canalizacin

Fuente de informacin: Cmo se enter del consultorio?

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Profesional o Institucin que canaliza
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IV.

Estructura familiar

Cuntas personas viven su casa?___________________________________

Motivo y tiempo que tienen viviendo ah:
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NOMBRE

EDAD

Lic. Psicologa Educativa

Universidad Mixta Sabatina UII

PARENTESCO

ESTADO
CIVIL

OCUPACIN

Claudia Valadez Ledesma

Teora y tcnica de la entrevista

Descripcin de la relacin con:

Mama:
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Papa:
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Hermanos:
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Otros familiares:
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V. Condiciones generales de vida
1. Qu hace actualmente?
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2. Relaciones con sus jefes, superiores, compaeros, subalternos:
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Lic. Psicologa Educativa
Universidad Mixta Sabatina UII

Claudia Valadez Ledesma

Teora y tcnica de la entrevista

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3. Ambiciones laborales:
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4. Cambios de profesin, oficios o trabajo (frecuentes, circunstanciales y sus causas):
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5.

Cmo considera su situacin econmica?

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6.

Cmo es un da normal en su rutina?

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7.

Actividades que realiza y que son satisfactorias/Frecuencia

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Lic. Psicologa Educativa
Universidad Mixta Sabatina UII

Claudia Valadez Ledesma

Teora y tcnica de la entrevista

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8.

Actividades que realiza y que no son satisfactorias

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9.

Como se siente respecto a:

Familia:
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Amigos:
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Pareja:
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Lic. Psicologa Educativa

Universidad Mixta Sabatina UII

Claudia Valadez Ledesma

Teora y tcnica de la entrevista

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Escuela:
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Trabajo:
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10. Situaciones, actividades o personas con las que se siente satisfecho
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11. Situaciones, actividades o personas con las que se siente insatisfecho
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12. Cules son sus temores?
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13. Cmo reacciona ante ellos?
Lic. Psicologa Educativa
Universidad Mixta Sabatina UII

Claudia Valadez Ledesma

Teora y tcnica de la entrevista

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VI.

Condiciones generales de vivienda

Cuntos aos tienen viviendo en esa casa?

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Cmo describira el ambiente donde viven?
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Cmo es la casa donde viven?
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Considera que hay espacio suficiente?
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Cmo estn distribuidas las recamaras y dems espacios?
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Con que servicios cuenta?
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Lic. Psicologa Educativa
Universidad Mixta Sabatina UII

Claudia Valadez Ledesma

Teora y tcnica de la entrevista

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Cmo considera la seguridad en la zona donde viven?
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Cmo considera la higiene de su hogar?
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Cmo considera la higiene en su familia?
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VII.

Examen mental

Apariencia y conducta
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Lenguaje
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Pensamiento
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Lic. Psicologa Educativa
Universidad Mixta Sabatina UII

Claudia Valadez Ledesma

Teora y tcnica de la entrevista

Funcionamiento sensorial-motor
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Funcionamiento cognitivo
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Funcionamiento emocional
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Funcionamiento del juicio
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VIII.

Pruebas psicolgicas aplicadas y resultados

PRUEBA APLICADA

Lic. Psicologa Educativa

Universidad Mixta Sabatina UII

RESULTADOS

OBSERVACIONES

Claudia Valadez Ledesma

Teora y tcnica de la entrevista

IX.

Familiograma

X. Historia general de vidai

1. Gestacin (pre natalidad): Cmo tomaron la noticia del embarazo?
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Edad de la madre al nacer:
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2.

Parto:

Tipo de atencin:
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Por qu?
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Fue a trmino? SI ( ) NO ( ): Presentacin (utilizacin de Frceps, cesrea)
Postnatalidad:
Estatura al nacer:___________________________________________
Peso: ____________________________________________________
Permetro Ceflico:_________________________________________
Torxico: ____________________Llor:_______________________
Reflejos (...):
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Lic. Psicologa Educativa
Universidad Mixta Sabatina UII

Claudia Valadez Ledesma

Teora y tcnica de la entrevista

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3. Desarrollo Psicomotor:
Lenguaje:
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Juego:
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A QUE EDAD
Camin:
Control de esfnteres:
ENCOPRESIS si ( ) no ( )
CONTROL A LOS ( ) aos
ENURESIS si ( ) no ( )
CONTROL A LOS ( ) aos.
Motricidad fina:
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Motricidad gruesa:
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Movimiento de pinza:
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4. Alimentacin infancia:
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5. Crianza por parte de los padres:
Solo Madre:
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Lic. Psicologa Educativa
Universidad Mixta Sabatina UII

Claudia Valadez Ledesma

Teora y tcnica de la entrevista

Solo Padre:
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Otros parientes (indicar):
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6. Juego infantil:
Juega solo o con otros nios: Amigos imaginarios.
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7. Carcter y comportamiento en los primeros aos:
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8. Relacin social (niez):
Con los padres:
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Con los hermanos:
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Otros familiares:
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Conocidos:
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Lic. Psicologa Educativa

Universidad Mixta Sabatina UII

Claudia Valadez Ledesma

Teora y tcnica de la entrevista

Extraos de la misma edad o diferente edad:

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Grado de integracin a ellos:
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9. Escolaridad:
Ingreso a la escuela (se adapt?):
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Integracin con los condiscpulos:
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Comportamiento en el saln de clases:
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En las horas de esparcimiento: (recreo):
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Relacin con los dems:
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Aislamiento:
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Lic. Psicologa Educativa
Universidad Mixta Sabatina UII

Claudia Valadez Ledesma

Teora y tcnica de la entrevista

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10. Experiencias durante los estudios primarios (recurso y apoyo, problemas de conducta,
indisciplina):
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Dificultades acadmicas (cmo enfrentaba los exmenes):
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11. Experiencias durante la secundaria: recurso y apoyo, problemas conducta indisciplina):
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Dificultades acadmicas (cmo enfrentaba los exmenes):
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12. Experiencias durante los estudios superiores (recurso y apoyo, problemas de conducta,
indisciplina):
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Dificultades acadmicas:
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13. Problemas afectivos o conducta durante su niez:
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Lic. Psicologa Educativa

Universidad Mixta Sabatina UII

Claudia Valadez Ledesma

Teora y tcnica de la entrevista

14. Problemas afectivos en la Pubertad, desde la pubescencia cuando se dan los cambios
fisiolgicos y aumento del Ritmo Maduracional (caractersticas Sexuales Primarias y
Secundarias otras particularidades):
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15. Particularidades de la adolescencia:
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16. Problemas afectivos o de conducta en la Adolescencia:
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17. Grado de armona entre la Madurez Biolgica y Psicolgica:
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18. Desarrollo de la Voluntad (rapidez, decisin y ejecucin):
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19. Grado de autonoma en la deliberacin y la accin:
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20. Persistencia en el esfuerzo:
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21. Jerarqua de valores (concepcin de la vida y el mundo):
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Lic. Psicologa Educativa

Universidad Mixta Sabatina UII

Claudia Valadez Ledesma

Teora y tcnica de la entrevista

Estilo de vida: Sexualidad activa e inactiva:

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24. Hbitos e intereses (consumo de alcohol, drogas, etc.):
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25. Enfermedad y accidentes (desde la niez hasta la actualidad):
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26. Eleccin de profesin u Oficio (libre, influenciado o forzado):
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27. Conducta sexual (inicio y vida sexual, desde los juegos infantiles a la actualidad)
Relacin con las personas del mismo sexo y del sexo opuesto:
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28. Eleccin de la pareja:
Le cuesta trabajo elegir pareja?:
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Fiel y exigente?:
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Lic. Psicologa Educativa

Universidad Mixta Sabatina UII

Claudia Valadez Ledesma

Teora y tcnica de la entrevista

Noviazgo (nmero y duracin de ellos)

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Matrimonio (edad del paciente y la pareja)
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Qu opina del matrimonio?:
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Particularidades del da de la boda:
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Vida Matrimonial (armona o desarmona conyugal):
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Separacin:
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Divorcio (causas)
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30. Problemas y periodos crticos particularidades del climaterio, menopausia y edad
crtica:
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Lic. Psicologa Educativa
Universidad Mixta Sabatina UII

Claudia Valadez Ledesma

Teora y tcnica de la entrevista

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XI.

Antecedentes mdicos y/o psicolgicos del paciente y familiares

Padece alguna enfermedad?

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Consume algn tipo de medicamento, alcohol o droga?
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Con que frecuencia?
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Cmo se siente cuando no consume o ingiere el medicamento, alcohol o droga?
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Ha recibido algn otro tratamiento psicolgico?
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Motivo
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_________________________________________________________________________

Lic. Psicologa Educativa

Universidad Mixta Sabatina UII

Claudia Valadez Ledesma

Teora y tcnica de la entrevista

ANTECEDENTES FAMILIARES
1. Rama Paterna:
Abuelo:
Abuela:
Padre:
Tos paternos:

2. Rama materna:
Abuelo:
Abuela:
Padre:
Tos maternos:

3. Hermanos (as):

4. Esposo (a):

5. Hijos:

XII.

Diagnstico

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Lic. Psicologa Educativa
Universidad Mixta Sabatina UII

Claudia Valadez Ledesma

Teora y tcnica de la entrevista

Pronstico
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Propuesta de intervencin
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Seguimiento y evolucin
No. De sesin

Fecha

Observaciones

Firma responsable: ________________________________

Nombre: ________________________________________
Telf.: ___________________________________________
E-mail:__________________________________________
i

Salud mental comunitaria. (n.d). Recuperado el 06 de marzo de 2013 desde http://stores.lulu.com/psicologos911

Lic. Psicologa Educativa

Universidad Mixta Sabatina UII