HISTORIA CLINICA

Fecha______de_______________del________
Datos de identificacin:
NIO (A) - ADOLESCENTE

N- DE HISTORIA:

Nombres y Apellidos:_____________________________________________________________Edad:____________
Nombres de los Padres________________________________________________________Edades:______________
Lugar y fecha de Nacimiento:___________________________________________
C.I________________________
Sexo:_______________Inicio de edad escolar:___________ Grado de instruccin:__________________________
Telfono:______________________________________________
Religin:________________________________
Direccin:________________________________________________________________________________________
Referido por :_____________________________________________________________________________________
MOTIVO DE CONSULTA :___________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Datos prenatales:
Embarazo controlado:__________Deseado:_________De alto riesgo:_________Causa:______________
Enfermedad durante el embarazo:______________________________________Hipertension:_________
Paranatales y posnatales:
Parto normal______ Inducido_______Por cesaria______Con forc_______peso_________Talla_______C/C______
Anoxia________Hipoxia_______Crisi convulsiva_________Incubadora_______Tiempo__________Causa________
Inicio a Gatear_____________Inicio a Caminar____________control de esfnteres___________________________
Alimentacin materna hasta que edad______________________________________
Observacin:______________________________________________________________________________________
_________________________________________________________________________________________________
Datos de los Padres:
Madre
Nombre y Apellidos: _______________________________________________Edad:___________________________
Lugar y Fecha de Nacimiento:________________________________________________ C.I.____________________
Estado Civil:_________________________Profesion:_________________________Ocupacion:__________________
Domicilio:________________________________________________________________________________________
Lugar de Trabajo:________________________________________ Horario de Trabajo:_________________________
Padece alguna enfermedad:__________________________________Especifique:____________________________
Consumo Psicotoxicos: Alcohol_____________________Cigarrillo:___________________Otros:________________
Telefono:____________________________________________________Religion:_____________________________
Padre
Nombre y Apellidos: _______________________________________________Edad:___________________________
Lugar y Fecha de Nacimiento:________________________________________________ C.I.____________________
Estado Civil:_________________________Profesion:_________________________Ocupacion:__________________
Domicilio:________________________________________________________________________________________
Lugar de Trabajo:________________________________________ Horario de Trabajo:_________________________

Padece alguna enfermedad:__________________________________Especifique:____________________________

Consumo Psicotoxicos: Alcohol_____________________Cigarrillo:___________________Otros:________________
Telefono:____________________________________________________Religion:_____________________________
Representante (en caso de no vivir con los padres)
Nombre y Apellidos: _______________________________________________Edad:___________________________
Lugar y Fecha de Nacimiento:________________________________________________ C.I.____________________
Estado Civil:_________________________Profesion:_________________________Ocupacion:__________________
Domicilio:________________________________________________________________________________________
Lugar de Trabajo:________________________________________ Horario de Trabajo:_________________________
Parentescocon el nio-adolescente:__________________________________________________________________
Padece alguna enfermedad:__________________________________Especifique:____________________________
Consumo Psicotoxicos: Alcohol_____________________Cigarrillo:___________________Otros:________________
Telefono:____________________________________________________Religion:_____________________________
Ambiente Familiar:
Presencia de ambos padres_________o de una sola________ cual_____________calidad de relacin con la
madre________________________con el padre_________________________con hermanos___________________
Observacin:______________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
reas de Exploracin.
Enfermedades sufridas: ( edad )_____________________________________________________________________
Accidentes o traumatismo:__________________________________________________________________________
Antecedentes psicolgicos , pquiatricos o neurolgicos :________________________________________________
_________________________________________________________________________________________________
Tendencia a: ser comunicativo____________Pasivo____________Agresivo___________Desafiante____________
Disruptivo____________ Adaptacin escolar ( B-R-D ):________________Rendimiento escolar________________
Desarrollo Psicosexual: Menarquia_____________________1era eyaculacin_______________________________
Acoso sexual______________Maltrato__________________A presenciado Robos____________________________
Tipo de alimentacin :________________________________Hbitos al Dormir:______________________________
_________________________________________________________________________________________________
Posee alguna responsabilidad dentro o fuera del hogar:________________________________________________
_________________________________________________________________________________________________
Practica algn deporte:__________ Cual_______________________________________________________________
Consumo Psocotoxicos: Alcohol________________ Cigarrillo______________________Otros_________________
frecuencia___________________
Instrumento de Evaluacin:
THF MACHOVER:

Anlisis:

TEST DE L. BENDER:

FRASES DE HISTORIA PARA COMPLETAR:

(
)

OTRO

Sntesis Diagnostica:_______________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Clasificacin diagnostica: DSM IV , CIE 10____________________________________________________________
Anlisis conclusivo:________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Tratamiento:______________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Genitograma

Psiclogo en Formacin :_____________________________

Clnica I
Seccin " O "

HISTORIA CLINICA
Fecha______de_______________del________
Datos de identificacin:
ADULTO

N- DE HISTORIA:

Nombres y Apellidos:_____________________________________________________________Edad:____________
Estado civil:______________N- de hijos ______________Edades:_____________Ocupacion:___________________
Lugar y fecha de Nacimiento:___________________________________________
C.I________________________
Sexo:_______________ Grado de instruccin:_________________________Religion:________________________
Telfono:_______________________ Referido por:____________________________________________________
Direccin:________________________________________________________________________________________
MOTIVO DE CONSULTA :___________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Arreglo Personal y Actitud ante la Entrevista:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Sntesis Histrica :
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Ambiente Familiar:
Presencia de ambos padres___________o de una sola___________ cual_____________calidad de relacin con la
madre________________________con el padre_________________________con hermanos___________________
Con los hijos :_________________________________ Con la pareja:________________________________________

Estado Civil:______________________________________Tiene pareja actualmente:__________________________

Viven en el mismo domicilio:_______________________Vida matrimonial o conyugal:_______________________
_________________________________________________________________________________________________
Observaciones:____________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Ambiente Laboral:
Trabaja:________ Domicilio de la Empresa:____________________________________________________________
Horario de trabajo:________________________________Tiempo en la Empresa:_____________________________
Relacion con los jefes y superiores:___________________________________________________________________
Relacion con los compaeros de trabajo:______________________________________________________________
Ambiciones laborales:______________________________________________________________________________
Observaciiones:___________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
reas de Exploracin:
Enfermedades sufridas: ( edad )_____________________________________________________________________
Accidentes o traumatismo:__________________________________________________________________________
Antecedentes psicolgicos , pquiatricos o neurolgicos :________________________________________________
_________________________________________________________________________________________________
Tendencia a: ser comunicativo____________Pasivo____________Agresivo___________Desafiante____________
Participativo con el entorno :_________________________
Desarrollo Psicosexual: Menarquia_____________________1era eyaculacin_______________________________
Acoso sexual______________Maltrato__________________________Violacion______________________________
Tipo de alimentacin :________________________________Hbitos al Dormir:______________________________
_________________________________________________________________________________________________
Posee alguna responsabilidad dentro o fuera del hogar:________________________________________________
_________________________________________________________________________________________________
Practica algn deporte:__________ Cual_______________________________________________________________
Consumo Psocotoxicos: Alcohol________________ Cigarrillo______________________Otros_________________
frecuencia___________________
Instrumento de Evaluacin:
THF MACHOVER:

TEST DE L. BENDER:

Anlisis:

OTRO

OTRO

CONDUCTA PROBLEMA :____________________________________________________________________________

_________________________________________________________________________________________________
_________________________________________________________________________________________________
REFORZADOR:_____________________________________________________________________________________
_________________________________________________________________________________________________
INCITADOR DE LA CONDUCTA:_______________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Alteraciones de las funciones mentales:
Orientacin, Pensamiento , Conciencia , Memoria , Percepcin , Afectividad, Volicin.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Sntesis Diagnostica:_______________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Clasificacin diagnostica: DSM IV , CIE 10____________________________________________________________
Anlisis conclusivo:________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Tratamiento:______________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

Genitograma

Psiclogo en Formacin :_____________________________

Clnica I
Seccin " O "

__________
___________
_____________
_____________
__________
________
________
__________
_______
_______

______
_____

___C/C______
Causa________
_____________

_________
_______

__________
___________
___________
________
____________
____________
_____________
________

__________
___________
___________
________
____________

____________
_____________
________

__________
___________
___________
________
____________
___________
____________
_____________
________

cin con la
___________
_________
_______
_______
_______
_______

___________
___________
______________
_______
te____________
______________
______________
____________
____________
_______
_____________
_______
___________
_____________

__________
_______
_______

_________________
_________
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______

________
_______
_______
_______
_______
_______
_______

_______
_______
_______
_______
_______

____

__________
____________
_____________
___________
_________
________

__________
_______
_______

_______
_______
_______
_______

_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______

e relacin con la
___________
___________

____________
______________
_______
_________
_______
_______
_______
_______

___________
_____________
____________
____________
__________
_________
_______
_______
_______
_______

___________
___________
______________
_______
te____________

______________
__________
____________
_______
_____________
_______
___________
_____________

__________
_______
_______
_________
_______
___________
_______
_______

_______
_______
_______
_______
_______

__________
_______
_______

_________________
_________
_______
_______
_______
_______

_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
________
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______

____