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HISTORIA CLINICA PSICOLÓGICA
I. DATOS PERSONALES:
1. Nombres: ______________________________________________________________
2. Fecha de nacimiento: ________________
3. Edad actual: ______________________________
4. Domicilio: _____________________________________
5. Instrucción y/o tipo de instrucción: _________________________________
6. Estado civil: ___________________________________
7. Fecha Actual: _______________________
8. Historia Clínica:
II. MOTIVO DE CONSULTA:
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
III. HISTORIA DE LA ENFERMEDAD
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
IV. ANAMNESIS PERSONAL PATOLOGICA
1. Embarazo
__________________
2. Parto
__________________
3. Enfermedades o historia de las mismas.
V. DESARROLLO PSICOMOTRIZ
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
VI. ANTECEDENTES PATOLÓGICOS FAMILIARES
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
⚫ Resultados
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
⚫ Diagnóstico
__________________________________________________________________________________________________
__________________________________________________________________________________________________
⚫ Definición porcentual:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Oscar Narvaez Solarte
PSICOLOGO CLINICO
T.I 109840

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Guardado con Autorrecuperación de historia clinica.docx

  • 1. HISTORIA CLINICA PSICOLÓGICA I. DATOS PERSONALES: 1. Nombres: ______________________________________________________________ 2. Fecha de nacimiento: ________________ 3. Edad actual: ______________________________ 4. Domicilio: _____________________________________ 5. Instrucción y/o tipo de instrucción: _________________________________ 6. Estado civil: ___________________________________ 7. Fecha Actual: _______________________ 8. Historia Clínica: II. MOTIVO DE CONSULTA: ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ III. HISTORIA DE LA ENFERMEDAD _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ IV. ANAMNESIS PERSONAL PATOLOGICA 1. Embarazo __________________ 2. Parto __________________ 3. Enfermedades o historia de las mismas. V. DESARROLLO PSICOMOTRIZ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ VI. ANTECEDENTES PATOLÓGICOS FAMILIARES ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ⚫ Resultados ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ⚫ Diagnóstico __________________________________________________________________________________________________ __________________________________________________________________________________________________