FACULTAD DE MEDICINA HUMANA Y CIENCIAS DE LA SALUD

ESCUELA PROFESIONAL DE PSICOLOGIA HUMANA

Nro. 001

HISTORIA CLINICA

1. DATOS GENERALES

Nombre y Apellido: _____________________________________________

Fecha de Nacimiento: _________________________ Edad: ____________
Lugar de Nacimiento: ___________________________________________
Domicilio Actual: _______________________________________________
Grado de Instrucción: ___________________________________________
Nombre del Padre: _________________ Edad: ____ Ocupación: ________
Nombre de La Madre: _______________ Edad: ____ Ocupación: ________
Nro. De Hermanos: ____________________________________________
Referencia: ___________________________________________________
Fecha de Estudio: _____________________________________________

2. PROBLEMA ACTUAL
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3. HISTORIA PERSONAL
Gestación:
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Nacimiento:
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Niñez:
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Escolaridad:
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FACULTAD DE MEDICINA HUMANA Y CIENCIAS DE LA SALUD
ESCUELA PROFESIONAL DE PSICOLOGIA HUMANA

Pubertad-Adolescencia:
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Vida Sexual:
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Hábitos, intereses y actitudes:
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4. HISTORIA FAMILIAR:
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5. HISTORIA ECONÓMICA Y OCUPACIONAL:

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II. EXAMEN CLINICO PSICOLOGICO:

CARACTERISTICAS GENERALES DEL COMPORTAMIENTO:

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FACULTAD DE MEDICINA HUMANA Y CIENCIAS DE LA SALUD
ESCUELA PROFESIONAL DE PSICOLOGIA HUMANA

DESCRIPCION FISICA:
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CONCIENCIA Y NIVELES DE ALERTA:

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MOTRICIADAD:

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ACTITUD COLABORADORA:
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III. EXPLORACION DE LOS PROCESOS COGNITIVOS

a) Atención y concentración:
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b) Procesos perceptuales:
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c) Orientación:
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d) Memoria:
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e) Pensamiento:
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f) Lenguaje:
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FACULTAD DE MEDICINA HUMANA Y CIENCIAS DE LA SALUD
ESCUELA PROFESIONAL DE PSICOLOGIA HUMANA

g) Lectura y Escritura:
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h) Praxias y Lateralidad:
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i) Exploración de vida de afectiva, carácter y las actitudes:
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III. EVALUACION PSICOMETRICA:

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RESULTADO PSICOMETRICO:
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IV. PROCESO DIAGNOSTICO

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V. PROCESO TERAPEUTICO

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