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HISTORIA CLNICA
Cd. Jurez, Chih; ________________

A) DATOS PERSONALES

Edad:___________ Fecha de nacimiento: ___________________ Sexo:________

Estado civil_____________ Ocupacin:_______________ Telfono_________________

Domicilio: ___________________________________________________________________

Escolaridad:_____________ Nmero de hijos: ____________ Religin________________

Lugar de nacimiento.-_______________________ Tiempo de vivir en la ciudad ____________

Nmero de hermanos_________________ Lugar que ocupa________________________

DESCRIPCION GENERAL DEL PACIENTE

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D) HISTORIA PERSONAL

ANTECEDENTES

Comportamiento anterior al padecimiento____________________________________________

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INFANCIA

Padecimientos o enfermedades de la infancia:_______________________________________

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INFANCIA TEMPRANA: Aspectos generales de embarazo, parto, tipo de nacimiento, etc.

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CARACTER Y COMPORTAMIENTO DE LA INFANCIA TARDA.- Tipo de nio, juegos,

miedos, fobias, pesadillas, ambiente familiar, etc.
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ADOLESCENCIA

Padecimientos o enfermedades en la adolescencia: ___________________________________

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TIPO DE COMPORTAMIENTO.- Percepcin de los cambios fsicos, educacin sexual, etc.

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Relacin con sus padres:________________________________________________________

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Relacin con sus amigos:________________________________________________________

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Relacin con su familia:__________________________________________________________

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Experiencia escolar:____________________________________________________________
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Experiencias especiales:_________________________________________________________
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Tipo de carcter.- ______________________________________________________________

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EDAD ADULTA

Padecimientos o enfermedades: ___________________________________________________

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Tipos de caracter:_______________________________________________________________
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Actividades de tiempo libre_______________________________________________________

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Padecimientos o enfermedades de familiares u otras personas___________________________

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Comportamiento en su trabajo_____________________________________________________
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Metas y objetivos en la vida_______________________________________________________

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Fracasos_____________________________________________________________________
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Vida sexual____________________________________________________________________
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Sentimientos como madre o madre:_________________________________________________

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Sentimientos como esposo (a):____________________________________________________

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Sentimientos como persona:______________________________________________________

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Dinmica familiar actual__________________________________________________________

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D. ANTECEDENTES GENERALES

Consumo de drogas_____________________________________________________________
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Alcoholismo____________________________________________________________________
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Problemas mentales_____________________________________________________________
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Temores nocturnos_____________________________________________________________
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Miedos_______________________________________________________________________
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Tratamudez____________________________________________________________________
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Fobias________________________________________________________________________
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Timidez excesiva _______________________________________________________________

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Pesadillas_____________________________________________________________________
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Dificultades del sueo____________________________________________________________

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Sonambulismo_________________________________________________________________
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Rabietas:_____________________________________________________________________
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Enuresis:_____________________________________________________________________

Encopresis:____________________________________________________________________
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Onicofagia: ___________________________________________________________________
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Golpes en la cabeza:____________________________________________________________
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Tipo de nacimientos_____________________________________________________________
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Problemas en el nacimiento_______________________________________________________
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Otros:_______________________________________________________________________
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E. DATOS FAMILIARES

FAMILIOGRAMA
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CONYUGUE

Edad:_________ Ocupacin:__________________________________________________

Tiempo de casados: _______ Religin: ____________ Vivo: _____ Fallecido: ______

Estado actual de salud__________________________________________________________

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Tipo de caracter________________________________________________________________
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Tipo de relacin que lleva con el: __________________________________________________

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Fecha de nac.___/_____/_____Lugar de nacimiento.___________ Tiempo en la ciudad_______

Escolaridad_________________________

Hbitos_______________________________________________________________________
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Actividades en su tiempo libre_____________________________________________________

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Antecedentes patolgicos y objetos de observacin____________________________________

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Antecedentes familiares patolgicos y objetos de observacin____________________________

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Relacin con la familia de l (ella) _________________________________________________

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PADRE:

Edad: _________ Ocupacin: ________________________________________________

Aos de casados: _______ Religin:____________ Vivo:_____ Muerto:______

Estado actual de salud: _________________________________________________________

Tipo de carcter________________________________________________________________
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Tipo de relacin que lleva con el___________________________________________________

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Fecha de nac.___/_____/_____Lugar de nacimiento.___________ Tiempo en la ciudad_______

Escolaridad_________________________

Hbitos_______________________________________________________________________
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Actividades en su tiempo libre_____________________________________________________

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Antecedentes patolgicos y objetos de observacin____________________________________

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Antecedentes familiares patolgicos y objetos de observacin____________________________

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Relacin con la familia de ella _________________________________________________

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Relacin con su familia paterna____________________________________________________

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MADRE:

Edad: _________ Ocupacin: ________________________________________________

Aos de casados: _______ Religin:____________ Vivo:_____ Muerto:______

Estado actual de salud: _________________________________________________________

Tipo de carcter________________________________________________________________
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Tipo de relacin que lleva con ella__________________________________________________

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Fecha de nac.___/_____/_____Lugar de nacimiento.___________ Tiempo en la ciudad_______

Escolaridad_________________________
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Hbitos_______________________________________________________________________
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Actividades en su tiempo libre_____________________________________________________

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Antecedentes patolgicos y objetos de observacin____________________________________

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Antecedentes familiares patolgicos y objetos de observacin____________________________

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Relacin con la familia de ella ____________________________________________________

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Relacin con su familia materna____________________________________________________

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HERMANOS

EDAD

1. ___________________________________________________________________________

2.-___________________________________________________________________________

3.- ___________________________________________________________________________

4. ___________________________________________________________________________

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6.- .__________________________________________________________________________

Antecedentes patolgicos y objetos de observacin____________________________________

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Relacin con cada uno de ellos

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OTRAS PERSONAS QUE CONVIVEN CON EL PACIENTE EN EL HOGAR

NOMBRE PARENTESCO OCUPACION EDAD

F. EXAMEN MENTAL

Tiempo, lugar, espacio___________________________________________________________

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Exmenes de laboratorio_________________________________________________________

Impresin y apariencia en general.- Apariencia personal, edad que representa, uso de ropa,
marcha, postura, complexin y constitucin, reaccin hacia el terapeuta, etc.
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rea perceptual.- Atencin, concentracin, orientacin, edo. de conciencia, etc.

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rea intelectual.- Curiosidad o capacidad de observacin y exploracin, memoria reciente y

remota, nivel intelectual, conocimientos generales, juicios, organizacin, coherencia, capacidad
de abstraccin, nivel de introspeccin, lenguaje y comunicacin, fluidez, caractersticas de la voz,
etc.
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Emociones y afectividad.- Lo que siente el paciente, cmo lo expresa, estado de nimo,

irritabilidad, comunicacin no verbal, etc.
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Accin motora.- Nivel de energa, habilidades, planeacin y tiempo, propsitos, etc.

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Modelo tereputico_____________________________________________________________
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Pruebas psicomtricas aplicadas y resultados________________________________________

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Aploc_______________________________________________________________________________

Fuente de referencia___________________________________________________________________

Observaciones y comentarios___________________________________________________________
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