HISTORIA CLINICA PSICOLÓGICA

PARA ADICCIONES

I. DATOS DE FILIACIÓN
1. NOMBRE: ____________________________________________________________________
2. DNI.:____________________________________ SEXO: M____ F_____
3. EDAD: _______________ FECHA DE NACIMIENTO: _______________
4. LUGAR DE NACIMIENTO: ____________________________________
5. G. I.: ______________________________________
6. RELIGION: _________________________________
7. OCUPACION: _______________________________
8. DESOCUPADO POR ADICCION: SI: ____ NO: _____
9. ESTADO CIVIL: _____________________________
10. SEPARADO/ DIVORCIADO POR ADICCION: SI: ___NO:___
11. DOMICILIO: __________________________________________________________________
12. TELEFONO 1___________________ TELEFONO 2:______________________
13. PERSONA RESPONSABLE: ____________________________________________________
14. PARENTESCO: ______________________________
15. DIRECCION: __________________________________________________________________
16. TELEFONO: ____________________
17. LUGAR DE EVALUACION: _______________________________
18. EVALUADOR (A): ______________________________________________________________

II. ANTENCEDENTES FAMILIARES

2.1 ALCOHOLISMO:

PADRE_____ ABUELO PAT_____ ABUELO MAT_______

MADRE_____ ABUELO PAT_____ ABUELO MAT_______
TIOS: _____
OTROS FAMILIARES, ESPECIFICAR:
________________________________________________________________________________

1
2.2 PSICOSIS (AFECTIVA / ESQUIZOF.) ESPECIFICAR FAMILIAR:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

2.3 N'' DE HERMANOS: _____________ 2.4 ORDEN CRONOLOGICO: _______

2.5 CRIANZA:

2.5.1 PADRE
a) Autoritario/dominante _____ b) Pasivo/blando_____ c) Ausente (físico/psicológico)_____

2.5.2 MADRE
a) Autoritario/dominante ___ b) Pasiva/blanda ___ c) Ausente ___

OTRA FORMA DE CRIANZA PADRE: __________________________________

OTRA FORMA DE CRIANZA MADRE: __________________________________

2.6 PADRES SEPARADOS: SI. ______NO _____ EDAD DEL PACIENTE: _________________

2.7 PROBLEMAS FAMILIARES MIENTRAS CRECIA (4-15 AÑOS) :

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

2.8 VIVE CON:

1. SOLO____ 2. PADRES____3. FAM. PROPIA ____ 4.MADRE/PADRE____ OTRO FAMILIAR____
CONDICION: ________________________________

2.9 SOPORTE ACTUAL: ____________________________________________________________

2.10 OBSERVACIONES REFERENTES AL NUCLEO FAMILIAR (ACTITUD):

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

2
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

III. ANTECEDENTES PERSONALES

3.1 EMBARAZO: NORMAL____ DISTOSICO____
ESPECIFICAR____________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

3.2 PARTO: NORMAL____ DISTOSICO____

3.3 DESARROLLO PSIOMOTOR: NORMAL____ DISTOSICO____

3.4 ENURESIS: NO____ SI____ EDAD________

3.5 ESTUDIOS: PROBLEMAS DE ADAPTACIÓN: SI____ NO____

________________________________________________________________________________
________________________________________________________________________________

PRIMARIA: RENDIMIENTO: BAJO____ PROMEDIO____ ALTO_____

SECUNDARIA: RENDIMIENTO: BAJO____ PROMEDIO____ ALTO____

3.6 HIPERACTIVIDAD: SI_____ NO______ EDAD_______

COMENTARIOS DE LOS ESTUDIOS

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

3
ESTUDIOS SUPERIORES:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

3.7 TRABAJOS: NO: ____INFORMALES:____ ESTABLES: _____

COMENTARIO LABORAL
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

3.8 HISTORIA DE DISCORDIA EST. MARITAL O DIVORCIO: SI_____ NO_____

ESPECIFICAR:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

3.9 HABITOS O INTERESES:

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

3.10 DESARROLLO PSICOSEXUAL:

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

4
________________________________________________________________________________
________________________________________________________________________________

3.11 ASPECTOS RESALTANTES EN SU HISTORIA DE VIDA:

a) Infancia. b) Adolescencia. c) Juventud. d) Adultez.

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

IV. TRANSTORNOS DE PERSONALIDAD Y OTROS ANTECEDENTES

PSIQUIATRICOS: _________________________________________________________________

1. ANTISOCIAL______ 2. ESQUIZOIDE______ 3. ESQUIZOTIPICO______

4. PARANOIDE______ 5. BORDELINE______ 6. HISTRIONICO________
7. NARCISISTA______ 8. EVITANTE_______ 9. DEPENDIENTE_______
10. OBSESIVO COMPULSIVO______ 11.PASIVO AGRESIVO______

SINDROME DE PSICOPATIZACIÓN
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

OPERACIONALIZAR DIAGNÓSTICO
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

5
OTROS ANTECEDENTES:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

V. ENFERMEDAD ACTUAL
5.1 (Describir la historia de la enfermedad adictiva, desde su inicio y de manera cronológica,
detallando la forma de iniciación, dosis y frecuencia de consumo, consumo asociado con alcohol,
tabaco y otras drogas, así como circunstancias y estresores asociados. Para los casos de patología
psiquiátrica asociada, describir a continuación y de manera separada sus características y
evolución).
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

6
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

VI. HISTORIA DE DROGAS USADAS CON MAYOR FRECUENCIA

6.1 DROGA USADA: ____________ EDAD DE INICIO: ________ EDAD USO: ___________
USO ACTUAL: _______________ FRECUENCIA: ___________________________________
NIVEL DE CONSUMO: _____________________________________________________________
________________________________________________________________________________

COCAINA
________________________________________________________________________________
PBC
________________________________________________________________________________
HOJA DE COCA
________________________________________________________________________________
ANFETAMINAS
________________________________________________________________________________
MARIHUANA
________________________________________________________________________________
ALUCINOGENOS
________________________________________________________________________________
ALCOHOL
________________________________________________________________________________
BARBITÚRICOS
________________________________________________________________________________
SEDANTES / HIPNÓTICOS
________________________________________________________________________________
INHALANTES
________________________________________________________________________________

7
ESTIMULANTES DE VENTA ILICITA
________________________________________________________________________________
CODEINA
________________________________________________________________________________
TABACO
________________________________________________________________________________
CAFE
________________________________________________________________________________

COMENTARIOS:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

6.2 CAUSAS DEL CONSUMO DE DROGAS

SEGÚN EL PACIENTE:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

SEGÚN LA FAMILIA:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

8
6.3 CAUSAS DE MANTENCION DE CONSUMO
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

6.4 PERIODO CIEGO DE LA FAMILIA

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

6.5 TIEMPO MAXIMO DE ABSTINENCIA: ______________________________________________

CAUSAS: _______________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

6.6 ACTITUD FRENTE AL CONSUMO

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

6.7 PROBLEMAS POLICIALES

1. Problemas policiales / legales: SI____NO____

ESPECIFICAR: ___________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

2. Accidentes relacionados a adicción: SI___NO____

ESPECIFICAR: ___________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

9
3. Uso de emergencias: SI ____ NO____ (frecuencia, causas por drogas)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

VII. RESULTADOS DE LAS PRUEBAS PSICOLÓGICAS Y OTROS

INSTRUMENTOS DE EVALUACIÓN

VIII. IMPRESIÓN DIAGNOSTICA Y PROBLEMAS ACTUALES ASOCIADOS

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

XI. OBSERVACIONES Y RECOMENDACIONES

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

10
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

X. LISTADO DE CONDUCTAS PROBLEMAS

9.1 Conductas en Déficit

9.2 Conductas en Exceso

9.3 Conductas en debilitamiento

XI. ANÁLISIS FUNCIONAL DE LAS CONDUCTAS PROBLEMAS

XII. PLAN DE TRATAMIENTO

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

11
________________________
PSICOLOGO

12