H.CL.

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DEPARTAMENTO DE PSICOLOGIA

HISTORIA CLINICA
I DATOS GENERALES
Nombres y Apellidos_________________________________________________________
Edad_________________ Sexo________________________________________________
Lugar y Fecha de nacimiento:.__________________________________________________
Lugar entre Hnos. _________
Grado de instruccin.___________________
Ocupacin/Grado__________________Domicilio__________________________________
Religin. ________________
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Estado civil______________ Actualmente vive con:________________________________
Si es casado/a y/o conviviente llenar lo siguiente:
Nombre del/la esposo/sa_________________________________________Edad_________
Grado de Instruccin______________________Ocupacin___________________________
Informante_________________________
Evaluador__________________________
EN CASO DE NIOS :llenar lo siguientes datos
MADRE:
Nombre____________________________________Edad________________
Grado de Instruccin______________________Ocupacin_______________
PADRE:
Nombre____________________________________Edad________________
Grado de instruccin______________________Ocupacin_______________
II OBSERVACIONES GENERALES DE CONDUCTA

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III MOTIVO DE CONSULTA

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IV PROBLEMA ACTUAL
a) Tiempo:_________________________________________________________________
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b) Forma de inicio___________________________________________________________

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c) Sntomas principales_______________________________________________________
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d) Relato __________________________________________________________________
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e) Antecedentes clnicos_______________________________________________________
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V HISTORIA PERSONAL
Embarazo _______________________________________________________________
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Parto ___________________________________________________________________
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Control medico____________________________________________________________
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Alimentacin _____________________________________________________________
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Lenguaje ________________________________________________________________
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Motricidad _______________________________________________________________
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Control de esfnteres _______________________________________________________
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Sueo ___________________________________________________________________
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Escolaridad ______________________________________________________________

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Adolescencia y juventud____________________________________________________
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Hbitos e intereses ________________________________________________________
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Accidentes y enfermedades __________________________________________________
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Historia psicosexual _______________________________________________________
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Historia familiar __________________________________________________________
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Historia socioeconmica y ocupacional
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VI EXAMEN MENTAL
A. Apreciacin general
Apariencia____________________________________________________________
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Comportamiento y actividad psicomotriz____________________________________
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Actitud hacia el examinador_______________________________________________

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B Humor, Afecto y propiedad

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C Lenguaje__________________________________________________________________
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D Alteraciones sensoperceptivas_________________________________________________
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E Pensamiento_______________________________________________________________
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F Sensorio y Cognicin
Alerta y nivel de conciencia
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Orientacin_____________________________________________________________
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Memoria_______________________________________________________________
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Concentracin y atencin__________________________________________________
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Capacidad de lectura y escritura
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Habilidad visoespacial
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Pensamiento abstracto
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Consolidacin de la informacin y la inteligencia

G Control de impulsos
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H Juicio e Insight
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VII. DIAGNSTICO PRESUNTIVO Y/O DEFINITIVO
CIE 10_____________
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VIII. DIAGNSTICO FUNCIONAL
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IX. DIAGNSTICO MULTIAXIAL
Eje I_______________________________________________________________________:
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Eje II ______________________________________________________________________
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Eje III _____________________________________________________________________
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Eje IV _____________________________________________________________________
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Eje V _____________________________________________________________________
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XI. EVOLUCION:
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