Universidad Mariano Glvez

Facultad de Psicologa
Ficha Clnica para Adultos
DATOS GENERALES:

Nombres
y
apellidos
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Edad
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Sexo.
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Lugar
y
Fecha
de
Nacimiento.
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Direccin.
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Telfonos
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Numero de Hermanos _______________ Lugar que ocupa entre sus
hermanos ________
Estado
Civil
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Religin
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Nombre del esposo/a: _____________________________________ edad
_____________
Escolaridad
del
esposo/a:
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Tiene
hijos
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Cuantos
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Nombres y edades
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Escolaridad
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repetido
algn
grado___________________
Nombre
de
la
Madre
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edad
___________________
Ocupacin
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Nombre
del
padre
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edad
___________________
Ocupacin
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Fecha de inicio:
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Referido por:
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Motivo de Consulta.
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Historia del Problema Actual_
Factores precipitantes:
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Duracin del problema:
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Impacto familiar:
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Antecedentes:
Patolgicos
no
patolgicos
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Historia Familiar:
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Genograma:

Examen Mental.
Estados de Conciencia:
Concentracin
Alerta
esfuerzo
Obnulacin
Confusin
Somnolencia
Negligencia

Orientacin:
Persona

Tiempo
Espacio
Situacin

Atencin y/o

Funcional

Con

Concentrada
Lbil
Hace Asociaciones Fatiga
Sigue Indicaciones

Memoria:

Lenguaje:

Inmediata
Reciente
Remota
Visual
realidad
Verbal

Estructurado
Concreto
Ininteligible
Abstracto
Disritmico
Lgico
Dificultad de nominacin Buen contacto con la
Dficit Auditivo

Pensamiento:

Sigue indicaciones

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Pruebas psicomtricas Aplicadas:
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Criterios diagnsticos:
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Evaluacin multiaxial
Eje I:
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Eje II
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Eje III
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Eje IV:

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Eje V:
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Pronostico:
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Plan teraputico
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Notas Evolutivas:
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Observaciones
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FIRMA: ___________________________________

Nombre del Psiclogo estudiante: Heber Osiel Morales Lpez

No. De carne: 3772-06-7082