INFORME PSICOLÓGICO

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Fecha………………………… Nº Historia....................

I. DATOS PERSONALES

Nombre…………………………………………………………………….. CC…….………………
Edad………………….. Fecha de nacimiento…………………………… Sexo M F
Estado civil S  UL  C  Se.  D  V  Instrucción N  P S Su.  T
Procedencia………………………… Residencia………………………… Teléfono……………….
Domicilio…………………………………………………………………………………………………….
Profesión……………………………. Ocupación…………………………. Religión……………….
Condiciones de atención Propia voluntad SI  No  Solo SI  NO  Consciente Si  No 
II. MOTIVO DE CONSULTA O PROBLEMA ACTUAL
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Estudio socioeconómico…………………………………………………………………………………….
III. HISTORIA DE LA ENFERMEDAD
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IV. ESTRUCTURA FAMILIAR
Nombre Edad Parentesco Ocupación
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V. IMPRESIÓN DIAGNÓSTICA INICIAL

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VI. REACTIVOS PSICOLOGICOS
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VII. RESULTADOS

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VIII. DIAGNÓSTICO DIFERENCIAL
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IX. DIAGNÓSTICO

Eje I……………........................................................................................................................ .....................

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Eje II................................................................................................................................................................
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Eje III..............................................................................................................................................................
Eje IV..............................................................................................................................................................
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Eje V................................................................................................................................................................

X. PRONÓSTICO
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XI. TRATAMIENTO
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XII. RECOMENDACIONES
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Evaluador: ……………………………………….