Escolar Documentos
Profissional Documentos
Cultura Documentos
rea de Psicologa
Ficha Clnica
Nombre:
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Direccin:
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Lugar y fecha de nacimiento:
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Edad actual:
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Estado civil: ____________________________Religin: _______________________
Profesin: ______________________________Ocupacin:_____________________
Nombre del Cnyuge____________________________________________________
Raza:
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Fecha de consulta:__________________________telfono:____________________
MOTIVO DE CONSULTA:
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PROBLEMA ACTUAL:
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HISTORIA DE LA ENFERMEDAD ACTUAL:
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ANTECEDENTES:
a. Hereditarios:
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b. Congnitos:
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c. Patolgicos personales (desde la infancia):
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d. Fisiolgicos (nutricionales, de eliminacin):
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e. Ginecolgicos (mujeres) madurez sexual (ambos sexos):
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f. Quirrgicos:
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g. Hbitos y costumbres (personales)
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h. Educativos (ultimo grado cursado:
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i. Laborales (lugares donde ha trabajado, incluyendo el ltimo trabajo realizado):
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Datos de la Madre
Edad al casarse o
unirse
Edad actual
Ocupacin
Escolaridad
Lugar de Nacimiento
Edad:
Sexo:
Ocupacin:
OBSERVACIONES:
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DIAGNOSTICO O IMPRESIN CLINICA:
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PLAN TERAPETICO:
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PSICOTERAPIA:
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Firma