PROCESO BIENESTAR ESTUDIANTIL

SUBPROCESO ATENCIN EN SALUD

HISTORIA CLNICA DE PSICOLOGA

Cdigo: FBE.70
Versin: 03
Pgina 1 de 4

l. DATOS PERSONALES

No. Historia:____________
Fecha:_____________
Nombres:________________________________________
Apellidos:______________________________
Documento de identidad: T.I.___ C.C.___ No. _______________________________
Edad:______________ Sexo:__________ Estado Civil:______________
Lugar
y
fecha
de
Nacimiento:________________________________________________________________
Carrera:_______________________
Cdigo:_______________
Semestre:___________
Nivel:________
Crditos cursados: ____________
Crditos Aprobados: ____________
Promedio Acumulado: ________
Promedio del Semestre Anterior: _______
Direccin actual:________________________________________________________________________
Telfono: _____________
Direccin
de
la
Familia:
_____________________________________
Ciudad:____________________
Telfono: _______________
Ha recibido algn tipo de tratamiento psicolgico o psiquitrico:
______________________________________________________________________________________

ll. MOTIVO DE CONSULTA:

_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
lll. DEFINICIN DEL PROBLEMA:

EVOLUCIN:______________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

CAUSAS:__________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

ACCIONES REALIZADAS EN BUSCA DE SOLUCIN:

____________________________________________________
__________________________________________________________________________________________________

PROCESO BIENESTAR ESTUDIANTIL

SUBPROCESO ATENCIN EN SALUD

HISTORIA CLNICA DE PSICOLOGA

Cdigo: FBE.70
Versin: 03
Pgina 2 de 4

__________________________________________________________________________________________________

IMPLICACIONES: (a nivel familiar, social, acadmico, etc.):

__________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

lV. ESTRUCTURA Y FUNCIONALIDAD FAMILIAR:

FAMILIOGRAMA:
MIEMBRO

PARENTESCO

EDAD

ESCOLARIDAD

OCUPACIN

VINCULOS AFECTIVOS CONFLICTIVOS Y REDES DE COMUNICACIN:

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

V. HISTORIA PERSONAL:

INFANCIA:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

ADOLESCENCIA:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

VI. HISTORIA ESCOLAR:

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
VII. OBSERVACIONES: (descripcin fsica, lenguaje no verbal, actitud, etc.)
__________________________________________________________________________________________________

PROCESO BIENESTAR ESTUDIANTIL

SUBPROCESO ATENCIN EN SALUD

HISTORIA CLNICA DE PSICOLOGA

Cdigo: FBE.70
Versin: 03
Pgina 3 de 4

__________________________________________________________________________________________________
__________________________________________________________________________________________________

VIII. DIMENSIONES:

COMPORTAMENTAL: ______________________________________________________________________________
__________________________________________________________________________________________________

__________________________________________________________________________________

AFECTIVA: ________________________________________________________________________________________
__________________________________________________________________________________________________

__________________________________________________________________________________

SOMATICA:________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
COGNITIVA:_______________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
SOCIAL: __________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

IX. PRUEBA Y ANLISIS DE RESULTADOS:

PERSONALIDAD:___________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTELIGENCIA: ____________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
HABILIDADES:_____________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
OTRAS:___________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

X. IMPRESIN DIAGNSTICA:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
XI. TRATAMIENTO A SEGUIR:

PROCESO BIENESTAR ESTUDIANTIL

SUBPROCESO ATENCIN EN SALUD

HISTORIA CLNICA DE PSICOLOGA

Cdigo: FBE.70
Versin: 03
Pgina 4 de 4

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
EVOLUCIN

Sesin No. ________

Fecha: ______________________
Objetivo: __________________________________________________________________________________________
__________________________________________________________________________________________________
Descripcin: _______________________________________________________________________________________
__________________________________________________________________________________________________
Sesin No. ________
Fecha: ______________________
Objetivo: __________________________________________________________________________________________
__________________________________________________________________________________________________
Descripcin: _______________________________________________________________________________________
__________________________________________________________________________________________________
Sesin No. ________
Fecha: ______________________
Objetivo: __________________________________________________________________________________________
__________________________________________________________________________________________________
Descripcin: _______________________________________________________________________________________
__________________________________________________________________________________________________
Sesin No. ________
Fecha: ______________________
Objetivo: __________________________________________________________________________________________
__________________________________________________________________________________________________
Descripcin: _______________________________________________________________________________________
__________________________________________________________________________________________________
Sesin No. ________
Fecha: ______________________
Objetivo: __________________________________________________________________________________________
__________________________________________________________________________________________________
Descripcin: _______________________________________________________________________________________
__________________________________________________________________________________________________
Sesin No. ________
Fecha: ______________________
Objetivo: __________________________________________________________________________________________
__________________________________________________________________________________________________
Descripcin: _______________________________________________________________________________________
__________________________________________________________________________________________________

EVALUACIN REALIZADA POR:

____________________________________

PROCESO BIENESTAR ESTUDIANTIL

SUBPROCESO ATENCIN EN SALUD

HISTORIA CLNICA DE PSICOLOGA

Cdigo: FBE.70
Versin: 03
Pgina 5 de 4

CONTROL DE CAMBIOS

VERSIN

FECHA DE
APROBACIN

02

Abril 15 de 2009

- Inclusin de Control de Cambios.

- Inclusin de pgina y otros ajustes en el
encabezado.

03

Abril 23 de 2009

- Inclusin de Documento de identidad.

DESCRIPCIN DE CAMBIOS REALIZADOS