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HISTORIA CLÍNICA PSICOLÓGICA

1. DATOS DE IDENTIFICACIÓN
Nombre:…………………………………………………………………………………………………………………………………………………
Lugar y fecha de nacimiento:………………………………………………………………………………………………………………….
Edad:………………………………………………………………………………………………………………………………………………………
Sexo:………………………………………………………………………………………………………………………………………………………
Raza:………………………………………………………………………………………………………………………………………………………
Nivel de escolaridad:………………………………………………………………………………………………………………………………
Religión:………………………………………………………………………………………………………………………………………………….
Nombre de la madre:……………………………………………………………………………………………………………………………..
o Residencia:…………………………………………………………………………………………………………………………………
o Procedencia:………………………………………………………………………………………………………………………………
Nombre del Padre:…………………………………………………………………………………………………………………………………
o Residencia:…………………………………………………………………………………………………………………………………
o Procedencia:………………………………………………………………………………………………………………………………
Lugar de residencia:……………………………………………………………………………………………………………………………….
Dirección domiciliaria:………………………………………………………………………………………………………………….………..
Numero de historia clínica:……………………………………………………………………………………………………………..…….
Fecha de ingreso:……………………………………………………………………………………………………………………………………
Teléfono:………………………………………………………………………………………………………………………………………………..
2. MOTIVO DE CONSULTA
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3. HISTORIA DE LA ENFERMEDAD
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4. ANAMNESIS PERSONAL NORMAL Y PATOLÓGICA
Prenatal:…………………………………………………………………………………………………………………………………………………
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Natal:…………………………………………………………………………………………………………………………………………………..…
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Posnatal:……………………………………………………………………………………………………………………………………………..…
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Infancia:…………………………………………………………………………………………………………………………………………………
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5. ANAMNESIS FAMILIAR NORMAL Y PATOLÓGICA
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6. HISTORIA SOCIAL
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7. HISTORIA LABORAL
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8. HISTORIA PSICOSEXUAL
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9. EXAMEN DE FUNCIONES
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10. ESTUDIO PSICOLÓGICO
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11. DIAGNÓSTICO CLÍNICO Y CÓDIGO
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12. EVOLUCIÓN Y TRATAMIENTO
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13. PRONOSTICO
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14. FUENTE DE INFORMACIÓN
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Firma

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