Historia clínica

Datos generales
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Edad______________________ fecha de nacimiento_____________________________
Profesión u oficio__________________________________________________________
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Religión _________________________________________________________________
Estado civil _______________años de casado ______________ cuántos hijos_________
Teléfono ______________________________ Fecha de entrevista _________________

Familiar más cercano o responsable

Nombre_________________________________________________vinculo___________
Teléfono_________________________________________________________________

Motivo de consulta
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Queja principal
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Historia Personal
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Historia familiar
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Historia social
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Historia escolar
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Historia laboral
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Historia medica
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Personalidad pre mórbida
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psicodinamia
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Examen mental
Apariencia general
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Sensorio (M.I.A.O.)
 Memoria (remota, reciente e inmediata)
Remota ____________________________________________________________
Reciente ___________________________________________________________
Inmediata____________________________________________________
 Inteligencia _____________________________________________________
 Atención _______________________________________________________
 Orientación (persona, tiempo y espacio)
Persona __________________________________________________
Tiempo ___________________________________________________
Espacio ___________________________________________________

Contenido del pensamiento

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Auto cognición y juicio

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Lenguaje
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Estado de ánimo
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Sensopercepción
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Psicodinamia
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Impresión clínica
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DIAGNOSTICO:
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Aplicación e interpretación de pruebas psicométricas

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Pronostico
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Plan terapéutico
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Evoluciones
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Responsable _____________________________________
Fecha __________________________________________