HISTORIA CLINICA

Nº de Historia___________________ Código ____________________

Remisión_____________ Quien Remite _______________________________________________

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E.P.S __________________________________________

Ciudad/Municipio _______________________ Departamento ___________________________

Fecha de Evaluación _____________________________ Sexo F___M___

Nombres del niño

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Documento de identificación __________________________________________

Edad actual ______________________ Fecha de Nacimiento _____________________________

Dirección _______________________________________________________________________
Barrio ____________________________________Teléfono _______________________________
Colegio ______________________________________________ Curso_______________________

Nombre del Padre_________________________________________________________________

Edad __________ Ocupación________________ Convive con el niño: SI ____No____

Nombre de la Madre_______________________________________________________________

Edad __________ Ocupación ________________Convive con el niño: Si _____No____

Motivo de consulta
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Descripción del embarazo (complicaciones, situaciones estresantes, apoyo familiar)

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Antecedentes Médicos Personales (enfermedades, terapias, medicamentos, golpes, accidentes)

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Antecedentes Psicológico Personales (visitas, remisiones al psicólogo)

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Antecedentes académicos
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Antecedentes Médicos Familiares
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Antecedentes psicológicos familiares

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FIRMA PSICOLOGO (A) EN FORMACIÓN