HISTORIA CLÍNICA PSICOLÓGICA

Fecha………………………… Nº Historia....................I. DATOS PERSONALESNombre …………………………………………………………….. CC…….………………

Edad …..………….. Fecha de nacimiento 09-04-97……………… Sexo M F

Estado civil S UL C Se. D V Instrucción N P S Su. T

Procedencia………………………… Residencia………………………… Teléfono……………….

Domicilio…………………………………………………………………………………………………….

Profesión……………………………. Ocupación…………………………. Religión……………….

Condiciones de atención Propia voluntad SI No Solo SI NO Consciente Si No

II. MOTIVO DE CONSULTA O PROBLEMA ACTUAL

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Estudio Socio-económico…………………………………………………………………………………

HISTORIA DE LA ENFERMEDAD

a. Enfermedad actual y evolución………………………………………………..

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ESTRUCTURA FAMILIAR

Nombre Edad Parentesco Ocupación

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Genograma

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a. Grupo familiar de origen……………………….............................................................................

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b. Grupo familiar propio…………………………………………………………………………………

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Antecedentes patológicos familiares……………………………………………………………………….

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Familiar responsable……………………………………………………………………………………….

III. PSICOANAMNÉSIS PERSONAL, NORMAL Y PATOLÓGICA

a. Etapaprenatal….……………………………………………….

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b. Etapa natal……..…......………………………………………………………………………………..

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c. Etapa postnatal………………………………………………………………………………………...

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d. Infancia……………………………..………………………………………………………………......

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e. Pubertad………..…………………………………………………………………………………..

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f. Adolescencia……………………………………………………………………………………………

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g. Juventud………………………………………………………………………………………………..

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h. Adultez………………………………………………………………………………………………….

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i. Madurez y senectud……………………………………………………………………………………

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PSICOANAMNÉSIS SOCIAL NORMAL Y PATOLÓGICA

a. Historia escolar………………………………………………………………………………………...

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b. Historial social……………………….…………………………………………..……………………..

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c. Historial laboral………………………………………………………………………………………..

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d. Historial psicosexual…………………………………………………………………………………...

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IV. ANAMNÉSIS MÉDICA

a. Enfermedades más relevantes………………………………………………………………………....

b. Intervenciones quirúrgicas………..…………………………………………………………………..

V. EXAMEN DE EXPLORACIÓN MENTAL

a. Consciencia……………………………………………………………………………………………..

Orientación autopsíquica……………….. alopsíquica……………….. Somatopsíquica…………..

Vigilia……………………...……………… Consciencia de enfermedad……………………………….

b. Atención...................................................................................................................................................

c. Sensopercepciones..................................................................................................................................

d. Memoria………………………………………………………………………………………………...

e. Afectividad……………………………………………………………………………………………...

f. Inteligencia……………………………………………………………………………………………..

g. Pensamiento…………………………………………………………………………………………….

h. Lenguaje………………………………………………………………………………………………..

i. Voluntad..................................................................................................................................................

j. Instintos………………………………………………………………………………………………...

k. Hábitos………………………………………………………………………………………………….

l. Juicio y razonamiento………………………………………………………………………………….

VI. REACTIVOS PSICOLOGICOS

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VII. RESULTADOS

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VIII. DIAGNÓSTICO DIFERENCIAL

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IX. DIAGNÓSTICO

Entidad clínica…............................................................................................................................................

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Personalidad...................................................................................................................................................

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X. PRONÓSTICO

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XI. TRATAMIENTO

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XII. RECOMENDACIONES

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MODELO DE EVALUACIÓN CASIC

AREA COGNITIVA

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AREA AFECTIVA

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AREA SOMÁTICA

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AREA INTERPERSONAL

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AREA CONDUCTUAL Y COMPORTAMENTAL

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