UNIVERSIDAD ARTURO MICHELENA

FACULTAD DE CIENCIAS ECONOMICAS Y SOCIALES

ESCUELA DE PSICOLOGIA
Prof. Licdo. Juan Pablo Silva
Asignatura: Psicodiagnostico general

Historia Clnica
Multimodal de Lazarus
Fecha:____/____/______
I.

IDENTIFICACIN DEL PACIENTE.

Nombres:___________________________________ C.I N#: V___, E____: _______________
Apellidos:____________________________________ Fecha de Nacimiento:_______________
Edad:________ Sexo:_________ Estado Civil: S:_______/ V:_______/ C:_______/ D:________
Grado de Instruccin:____________________________ Ocupacin u Oficio:________________
Direccin de Habitacin:__________________________________________________________
Telfonos: ________________________/________________________

II.

MOTIVO DE CONSULTA.
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III.

ENFERMEDAD ACTUAL. (al momento de la entrevista)

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IV.

ANTECEDENTES:

Estados Somticos de Paciente:

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Adolescencia:
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Adultez:
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Composicin familiar:
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Comunicacin:
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Situacin Socio- econmica:
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Problemas Familiares y Conyugales:
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V.

EXAMEN MENTAL.

Conciencia:
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 Orientacin:
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Lenguaje:
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Pensamiento:
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Afectividad:
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Exploracin por rea:
o Cognitivo:
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o Afectivo:
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o Somtica:
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o rea Interpersonal:
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o Conducta:
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VI.

DATOS FILIATORIOS.

Padre: _____________________
Edad: ______ V: _________/ M: _______
Ocupacin:__________________________________
Madre: _______________________
Edad: ______ V: ________/ M: ________
Ocupacin: __________________________________
Hermanos:
Nombre: _____________________
Edad: ______ V: ________/ M: ________
Ocupacin: _______________________________
Nombre: ______________________
Edad: ______ V: ________/ M: ________
Ocupacin: ________________________________

Antecedentes psiquitricos:
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VII.

INTRUMENTO DE EVALUACIN

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VIII.

DIAGNOSTICO PRESUNTIVO

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IX.

RECOMENDACIONES

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