HISTORIA CLINICA

Nombre del entrevistador o terapeuta:____________________________

Supervisor:_________________________________________________

Fecha de admisin:__________

FICHA DE IDENTIFICACION

Nombre:________________________________________________________

Sexo:___________ Fecha de nacimiento:_____________________

Edad:___________ Lugar de nacimiento:______________________

Estado civil:__________ No. De hijos:______________

Escolaridad:___________________ Ocupacin:_________________

Religin:___________________ Direccin:_______________________

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Telfono:_________________________

Informante:______________________________________________________

MOTIVO DE CONSULTA

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DESARROLLO DEL PROBLEMA

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DESCRIPCION DEL PACIENTE

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CONDUCTA OBSERVADA

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EXAMEN MENTAL

Estado de consciencia

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Conducta motora

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Afecto

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ESTADO COGNOSCITIVO

Atencin

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Recuerdo inmediato

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Concentracin y vigilancia

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Orientacin

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Lenguaje

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Fluidez

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Repeticin

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Denominacin

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MEMORIA

Mediano plazo

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Largo plazo

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Verbal

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Visual

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PENSAMIENTO

Proceso

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Contenido

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Introspeccin

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JUICIO DE REALIDAD

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ANTECEDENTES FAMILIARES

Nombre de la madre:______________________________________________

Edad:________________ Ocupacin:_________________________________

Escolaridad:_____________________________________________________

Padecimientos mentales:___________________________________________

Padecimientos fsicos:_____________________________________________

Alcoholismo, drogadiccin, farmacodependencia:________________________

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Nombre del padre:________________________________________________

Edad:________________ Ocupacin:_________________________________

Escolaridad:_____________________________________________________

Padecimientos mentales:___________________________________________

Padecimientos fsicos:_____________________________________________

Alcoholismo, drogadiccin, farmacodependencia:________________________

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Hermanos en (orden cronolgico):

Nombre Edad Edo. Civil Ocupacin

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HISTORIA PERSONAL

Edad de la madre al embarazarse:____________________________________

Edad del padre al momento del embarazo:_____________________________

Enfermedades durante el embarazo:__________________________________

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Complicaciones:__________________________________________________
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Conducta de los padres durante el embarazo:___________________________

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Tipo de parto:_________________________ Duracin:_____________

Condiciones generales al nacimiento:_________________________________

Peso:_________________ Talla:______________ Apgar:______________

Comentarios:_____________________________________________________
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INFANCIA

Edad a la que se logro:

Control de cuello:________ Sedentacin:______ Bipedestacin:___________

Marcha:____________ Control de esfnteres:________ Uretral:_____________

Anal:___________ Actitud del nio:___________________________________

Actitud de los padres:______________________________________________

Comentarios:_____________________________________________________
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Manifestaciones patolgicas hasta antes de los 5 aos:

Tics:__________________ Terrores nocturnos:__________________

Enuresis:__________________ Encopresis:__________________
Tartamudez:________________ Onicofagia:___________________

Otros:__________________________________________________________

Enfermedades, cirugas, accidentes:__________________________________

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HISTORIA ESCOLAR (PRIMARIA) -INFANCIA-

Edad de inicio y termino:_______________ Tipo de escuela:_______________

Conducta en la escuela:_______________ Tipo de estudiante:_____________

Problemas de aprendizaje:__________________________________________
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Actitudes hacia sus compaeros:_____________________________________

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Actitudes hacia maestros y autoridades:_______________________________

Manifestaciones patolgicas (despus de los 5 aos) (tics, pesadillas,

agresividad, hiperactividad, depresin, apata, miedo, dislalia, discalculia,
dislexia, etc.)
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HISTORIA ESCOLAR (SECUNDARIA) -ADOLESCENCIA-

Edad de aparicin y actitud ante el hecho:

Menarqua:______________________________________________________

Primera eyaculacin nocturna:_______________________________________

De quin o cmo obtuvo informacin de carcter sexual:_________________

Historia escolar:__________________________________________________
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Intereses vocacionales:____________________________________________

Historia ocupacional:_______________________________________________
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Relaciones de pareja:______________________________________________
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Enfermedades, cirugas, accidentes:__________________________________
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ADULTEZ (VIDA SEXUAL)

Primera relacin sexual:____________________________________________

Embarazos (edad y circunstancias):___________________________________

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Aborto (s):_______________________________________________________

Nmero de compaeros sexuales:____________________________________

Mtodos de planificacin sexual:_____________________________________

Alteraciones o enfermedades de transmisin sexual:_____________________

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Preferencia sexual:________________________________________________

Relacin conyugal:________________________________________________

Actitud:_________________________________________________________

ANTECEDENTES PERSONALES GENERALES

Historia vocacional y/o laboral:_______________________________________

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Relaciones de pareja:______________________________________________
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Actividades sociales y recreativas:____________________________________

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DIAGNOSTICO:__________________________________________________
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PRONOSTICO:___________________________________________________
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PLAN DE TRATAMIENTO:_________________________________________
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OBSERVACIONES:_______________________________________________
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