HISTORIA CLNICA

1. Datos generales
nombre:
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Sexo:
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Edad:

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Escolaridad:

Origen y procedencia: __________________ Ocupacin: _________________________

Estado civil: ______________________
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Religin:

Nombres de los padres y/o responsable, edad, escolaridad, ocupacin, estado civil:
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2. Motivo de consulta

Es la razn por la que el paciente busca o es referido al servicio profesional.

Es la preocupacin que lleva a los padres de un nio a buscar consulta.
Se escribe en forma breve, textual y entrecomillada y se hace referencia de quien
informa y de su relacin con el paciente.

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3. Historia del problema actual

Se refiere al curso del padecimiento, expuesto en el motivo de consulta, desde su

inicio hasta el momento actual; cundo y cmo empez a manifestarse y a qu
acontecimientos se asocia su aparicin.

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4. Historia personal (historia escolar y social)

Datos del periodo pre, peri y postnatal (condiciones anteriores al embarazo, parto)
Desarrollo psicomotor
Lenguaje
Alimentacin
Hbitos de sueo

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5. Perfil social

Relacin del paciente con personas fuera del grupo familiar o escolar
Habilidades o limitaciones y preferencias en cuanto a relaciones sociales

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6. Historia escolar

Edad en la que inici en la escuela

Adaptacin
Relacin con los maestros y compaeros
comportamiento

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5. Personalidad bsica

Descripcin de las caractersticas psicolgicas del paciente de acuerdo a la

informacin obtenida en la Anamnesis, Entrevistas y observaciones realizadas

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6. Historia familiar

Estructura familiar (miembros que componen la familia y conviven con el paciente)

Dinmica familiar (relaciones e interacciones que se establecen entre cada uno de
los miembros y el paciente).
Actitudes de la familia frente a otros ambientes del paciente

Genograma

Anlisis de las pruebas aplicadas

Antecedentes
Aspectos mdicos
Psicolgicos
Obsttricos
Traumticos

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7. Examen mental
Resultado del examen mental (evaluacin de las funciones psicolgicas):

Apariencia general y actitud

Estado de conciencia
Estado de nimo
Actividad motora
Asociacin y flujo de ideas y caractersticas del lenguaje
Contenido de ideas
capacidad sensorial
Memoria
Pensamiento

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8. Impresin clnica

Se formula luego del anlisis de la informacin obtenida.

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9. Focalizacin.
10. Jerarquizacin.

aqu se incluyen las esferas

(reas) de vida del paciente, y la
identificacin de problemas del
paciente (focalizacin)

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11. Diagnstico:
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12. Fundamentacin de la impresin clnica o el diagnstico:
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13. Plan de orientacin psicolgica:

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a) Objetivo del tratamiento:

Qu se persigue alcanzar mediante la atencin, sobre qu aspectos o reas y

cmo se va a intervenir. Frecuencia y duracin de las sesiones. Adems de la
frecuencia y duracin se debe incluir el tiempo estimado que durar el tratamiento.

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b. Tcnicas a emplear

Tcnicas elegidas de acuerdo a las caractersticas del caso y orientacin

teraputica

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c. Abordamiento a nivel de los distintos ambientes del paciente (esferas)

Familiar:

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Escolar:

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Social:

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14. Fundamentacin de la orientacin psicolgica.

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15. Conclusiones y recomendaciones

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Nombre y firma del paciente
Nombre y firma del Profesional
que remite