Historia Clínica
Datos de identificación:
Nombre y apellido del paciente: _______________________________________________
Lugar y fecha de nacimiento: _________________________________________________
Edad: ___________________________sexo:_________________C.I.________________
Grado de instrucción: ________________________Ocupación actual: ________________
Dirección de habitación: _____________________________________________________
____________________________________________Teléfono:_____________________
Dirección de empleo: _______________________________________________________
____________________________________________Teléfono: _____________________
Religión: ____________________________ Profesional Tratante: ___________________
Referido por : _____________________________ Fecha de consulta: ________________
Motivo de consulta (síntomas, inicio, severidad, porque busca tratamiento en
este momento, fuentes de referencia)
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Situación actual del paciente
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Contactos con otros profesionales. Tx. Ambulatorio, interno y
hospitalizaciones. Medicación pasada y presente.
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Antecedentes personales
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Antecedentes médicos
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Biografía
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Historia escolar
______________________________________________________________
______________________________________________________________
______________________________________________________________
Historia de relaciones interpersonales
______________________________________________________________
______________________________________________________________
______________________________________________________________
Historia conyugal
______________________________________________________________
______________________________________________________________
______________________________________________________________
Historia laboral
_____________________________________________________________
______________________________________________________________
______________________________________________________________
Historia militar
______________________________________________________________
______________________________________________________________
Historia familiar y su dinámica
_____________________________________________________________
______________________________________________________________
______________________________________________________________
Genitograma
Historia de abusos, traumas, negligencia. Perdidas.
______________________________________________________________
______________________________________________________________
______________________________________________________________
Historia legal
______________________________________________________________
______________________________________________________________
______________________________________________________________
Hábitos psicobiológicos. Alimentación, eliminación, sueño. Consumo de
sustancia.
______________________________________________________________
______________________________________________________________
______________________________________________________________
Examen mental
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
_____________________________________________________________
Diagnóstico
Eje I._________________________________________________
Eje II. ________________________________________________
Eje III. _______________________________________________
Eje IV. _______________________________________________
Eje V. _______________________________________________
Observaciones:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Firma del Psicólogo (a)
