Universidad Yacambu

Carrera: psicologa
Intervencin y tratamiento clnico
Protocolo de atencin para trastornos relacionados con sustancias

I. HISTORIA CLNICA DE ADULTOS

Identificacin personal
Nombre completo
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Edad _________________ Fecha de nacimiento
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Estado civil __________________________Ocupacin
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Nacionalidad ________________________Religin
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Direccin
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Telfono de casa ____________________Celular
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Persona que lo refiri
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Motivo de consulta
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Conciencia de la enfermedad
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Conducta problema:
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Conducta meta
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Historia del problema actual

A) Fecha de inicio y duracin del problema.

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B) Describa la severidad del problema

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C) Factores precipitantes (estresores psicosociales, si hubieran)

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Tutora: Msc. Dessire Rodrguez. Psiclogo clnico. FVP 7485

USO ACADEMICO
 Universidad Yacambu
Carrera: psicologa
Intervencin y tratamiento clnico
Protocolo de atencin para trastornos relacionados con sustancias

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D) Impacto del trastorno en el sujeto y en la familia.

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E) Describa las conductas o comportamientos despus que se iniciaron los problemas

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F) Dgame cmo ha intentado solucionar este problema y cules han sido los resultados
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Antecedentes personales

Antecedentes prenatales, perinatales y postnatales

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Desarrollo psicoevolutivo
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Antecedentes de salud fsica y mental

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Consumo de sustancias
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Antecedentes escolares
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Tutora: Msc. Dessire Rodrguez. Psiclogo clnico. FVP 7485

USO ACADEMICO
 Universidad Yacambu
Carrera: psicologa
Intervencin y tratamiento clnico
Protocolo de atencin para trastornos relacionados con sustancias

Antecedentes laborales
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Eventos significativos de su vida

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Antecedentes familiares

Enfermedades fsicas
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Psicopatolgicas
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Consumo de sustancias
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Antecedentes penales
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Dinmica Familiar:
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Genograma:

Tutora: Msc. Dessire Rodrguez. Psiclogo clnico. FVP 7485

USO ACADEMICO
 Universidad Yacambu
Carrera: psicologa
Intervencin y tratamiento clnico
Protocolo de atencin para trastornos relacionados con sustancias

Hbitos psicobiolgicos

Alimentacin
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Ciclo de vigilia y sueo

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Higiene
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Ejercicios fsicos
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Examen mental

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Impresin diagnostica:
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Tutora: Msc. Dessire Rodrguez. Psiclogo clnico. FVP 7485

USO ACADEMICO