ENTREVISTA INICIAL

Fecha:

Entrevistador: _____________________________

Datos generales.
Nombre: ______________________________ Edad: _________ Sexo: ___
Estado civil: ________________________ Hijos: _____________________
Ocupacin: __________________________ Tel: ______________________
Direccin: ______________________________________________________
Fuente de referencia: ____________________________________________
Presentacin del problema.
Queja principal (en los trminos del paciente): _________________________
_______________________________________________________________
_______________________________________________________________
Historia inmediata del desarrollo del problema: ________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Definicin del problema: __________________________________________
_______________________________________________________________
_______________________________________________________________
Antecedentes: __________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Consecuentes: __________________________________________________
_______________________________________________________________
_______________________________________________________________

Duracin del problema: ___________________________________________

_______________________________________________________________
Frecuencia de ocurrencia: _________________________________________
_______________________________________________________________
Intentos anteriores de solucionarlo: _________________________________
_______________________________________________________________
Intentos anteriores por solucionar otros problemas: ____________________
_______________________________________________________________
Historia mdica.
Enfermedades significativas: _______________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Hospitalizacin(es): ______________________________________________
_______________________________________________________________
_______________________________________________________________
Muertes familiares: ______________________________________________
_______________________________________________________________
_______________________________________________________________
Medicacin actual: _______________________________________________
_______________________________________________________________
_______________________________________________________________

ENTREVISTA INICIAL
Impresin clnica.
Apariencia fsica: ________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

Conductas durante la entrevista: ____________________________________

_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Estado de actividad: ______________________________________________
_______________________________________________________________
Orientacin: ____________________________________________________
_______________________________________________________________
Habilidades sociales: _____________________________________________
_______________________________________________________________
_______________________________________________________________

Cooperacin y motivacin para el tratamiento: ________________________

_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Manifestaciones de problemas de organicidad: ________________________
_______________________________________________________________
_______________________________________________________________

Sugerencias para los procedimientos de tratamiento: ___________________

_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

Otras observaciones: _____________________________________________

_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________