UNIVERSIDAD CENTRAL DE NICARAGUA

Agnitio

Ad Verum Ducit
FACULTAD DE PSICOLOGIA

EXAMEN MENTAL
FECHA: __________

I.

Datos Generales:

Nombre __________________________________________________

Edad: ______

Sexo: ___

Lugar y Fecha de Nacimiento: _____________________________________________________________

Religin: _________________________Escolaridad: ____________________________________________
Estado Civil: ___________________ Ocupacin: ____________________________ Direccin __________
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Telfono __________________

II.

Motivo de la Consulta:

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III.

Historia de la enfermedad actual

Sntomas

inicios

de

la

enfermedad

actual

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Circunstancias

acontecimientos

vitales

con

la

aparicin

de

la

enfermedad

actual.

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Curso de la enfermedad actual (continuo, terminante, critico) _____________________________________

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IV.

Cambio previo al nivel de la adaptacin producido por la

enfermedad a nivel
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V. Tratamiento recibido

Dosis ________________________________________________________________________________
Duracin _____________________________________________________________________________
Efecto
secundario
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Hospitalizacin _________________________________________________________________________
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VI.

Historia familiar
Datos generales de los miembros de la familia

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Ambiente familiar
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Antecedentes de patologa somtica o psiquitrica

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VII.

Nombre de los padres: _________________________________________________________________

Ocupacin: ___________________________________________________________________________
Nivel Acadmico: ______________________________________________________________________
Relacin con sus familiares: _____________________________________________________________
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Existencia de Enfermedades o patologas familiares: _______________________________________
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Papel que juega en la Familia: ___________________________________________________________

Historia personal

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Prenatal ______________________________________________________________________________
Parto ________________________________________________________________________________
Niez ________________________________________________________________________________
Adolescencia __________________________________________________________________________
Adultez_______________________________________________________________________________
Vicios Cmo y con quin lo hace? _______________________________________________________
Problemas Familiares: __________________________________________________________________
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Actividad
Ocupacional
o
laboral,
si
est
satisfecho?
________________________________________
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Aspiraciones:
_________________________________________________________________________
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Proyectos: ____________________________________________________________________________
Iniciativas: ____________________________________________________________________________
Participacin
con
la
familia,
vecinos:
______________________________________________________

Intereses religiosos, culturales y polticos: ________________________________________________

Actitud
frente
a
la
enfermedad:
___________________________________________________________
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VIII.

_____________________________________________________________________________________
Si
ha
estado
hospitalizado
Por
qu?:
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Nombre del Hospital ___________________________________________________________________
Enfermedades Fsicas importantes: ______________________________________________________
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Personalidad Pre mrbida

Anlisis

de

la

personalidad

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Actitudes
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Carcter ______________________________________________________________________________
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Estilo de Vida __________________________________________________________________________
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Intereses _____________________________________________________________________________
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IX.

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Evaluacin del estado mental

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X.

Diagnostico segn el DSM V y CIE 10

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XI.

Diagnstico diferencial
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XII.

Formulacin de los factores etiolgicos

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XIII.

Instrumentos psicopatolgicos aplicados

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XIV.

Pronostico
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XV.

Plan de intervencin y tratamiento

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EXAMINADO POR: ________________________________