ANAMNESIS

1. Datos Generales:
Nombre completo: ________________________________________________________
Edad: __________________________________________________________________
Fecha de nacimiento: _____________________________________________________
Rut: ___________________________________________________________________
Dirección: _______________________________________________________________
Ocupación [añadir curso si es estudiante]: ____________________________________
Carrera/Establecimiento: __________________________________________________
Estado Civil: _____________________________________________________________

2. Datos apoderado:
Nombre completo: ________________________________________________________
Parentesco con el/la paciente: ______________________________________________
Edad: ___________________________________________________________________
Fecha de nacimiento: ______________________________________________________
Rut: ____________________________________________________________________
Dirección: ______________________________________________________________
Ocupación: ______________________________________________________________
Estado civil: ______________________________________________________________
Fono Contacto: ___________________________________________________________

3. Motivo de consulta:
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4. Historia de la patología actual.

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5. Antecedentes patológicos personales.
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6. Antecedentes patológicos familiares (enfermedades crónicas de los miembros de
la familia):
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7. Antecedentes prenatales (Ocupación en contexto familiar, lugar de nacimiento,
como era la situación económica y social en contexto familiar, antecedente médicos
[hospitalizaciones], con quien vive en la actualidad, y estado actual de los miembros
de su familia).
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8. Historia escolar.

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9. Historia psicosexual (Etapa de desarrollo, inicio de vida sexual, estabilidad de parejas).

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10. Personalidad pre-mórbida (antes de la aparición del motivo de consulta):
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11. Socialización (descripción del entorno en el que se desenvuelve).
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12. Composición familiar y Ambiente Familiar ([Estructura y dinámica]

Parentesco, edad, ocupación).
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13. Vivienda (material de la vivienda, N° de habitaciones, etc.).
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14. Antecedentes religiosos (Familiares y pacientes)
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15. Impresión o hipótesis diagnósticas.
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16. Genograma.

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