1. HISTORIA CLÍNICA PSICOLÓGICA
1. DATOS DE IDENTIFICACIÓN
Nombre:…………………………………………………………………………………………………………………………………………………
Lugar y fecha de nacimiento:………………………………………………………………………………………………………………….
Edad:………………………………………………………………………………………………………………………………………………………
Sexo:………………………………………………………………………………………………………………………………………………………
Raza:………………………………………………………………………………………………………………………………………………………
Nivel de escolaridad:………………………………………………………………………………………………………………………………
Religión:………………………………………………………………………………………………………………………………………………….
Nombre de la madre:……………………………………………………………………………………………………………………………..
o Residencia:…………………………………………………………………………………………………………………………………
o Procedencia:………………………………………………………………………………………………………………………………
Nombre del Padre:…………………………………………………………………………………………………………………………………
o Residencia:…………………………………………………………………………………………………………………………………
o Procedencia:………………………………………………………………………………………………………………………………
Lugar de residencia:……………………………………………………………………………………………………………………………….
Dirección domiciliaria:………………………………………………………………………………………………………………….………..
Numero de historia clínica:……………………………………………………………………………………………………………..…….
Fecha de ingreso:……………………………………………………………………………………………………………………………………
Teléfono:………………………………………………………………………………………………………………………………………………..
2. MOTIVO DE CONSULTA
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………..
3. HISTORIA DE LA ENFERMEDAD
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………....
2. ...........................................................................................................................................................................
...........................................................................................................................................................................
...........................................................................................................................................................................
........................................................................................................................................................
4. ANAMNESIS PERSONAL NORMAL Y PATOLÓGICA
Prenatal:…………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………….…
……………………………………………………………………………………………………………………………………………………………….
Natal:…………………………………………………………………………………………………………………………………………………..…
…………………………………………………………………………………………………………………………………………………………….…
…………………………………………………………………………………………………………………………………………………………….…
Posnatal:……………………………………………………………………………………………………………………………………………..…
…………………………………………………………………………………………………………………………………………………………….…
……………………………………………………………………………………………………………………………………………………………….
Infancia:…………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………….…
……………………………………………………………………………………………………………………………………………………………….
5. ANAMNESIS FAMILIAR NORMAL Y PATOLÓGICA
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
6. HISTORIA SOCIAL
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
7. HISTORIA LABORAL
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………