HISTORIA CLINICA

l. DATOS PERSONALES

No. Historia:____________ Fecha:_____________

Nombres:________________________________________
Apellidos:______________________________
Documento de identidad: T.I.___ C.C.___ No. _______________________________
Edad:______________ Sexo:__________ Estado Civil:______________
Lugar y fecha de
Nacimiento:________________________________________________________________
Carrera:_______________________ Código:_______________ Semestre:___________
Nivel:________
Créditos cursados: ____________ Créditos Aprobados: ____________
Promedio Acumulado: ________ Promedio del Semestre Anterior: _______
Dirección actual:________________________________________________________________________
Teléfono: _____________
Dirección de la Familia: _____________________________________
Ciudad:____________________
Teléfono: _______________

Ha recibido algún tipo de tratamiento psicológico o psiquiátrico:

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ll. MOTIVO DE CONSULTA:

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lll. DEFINICIÓN DEL PROBLEMA:

 EVOLUCIÓN:______________________________________________________________________________________
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 CAUSAS:__________________________________________________________________________________________
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 ACCIONES REALIZADAS EN BUSCA DE SOLUCIÓN:

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 IMPLICACIONES: (a nivel familiar, social, académico, etc.):

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lV. ESTRUCTURA Y FUNCIONALIDAD FAMILIAR:

 FAMILIOGRAMA:

MIEMBRO PARENTESCO EDAD ESCOLARIDAD OCUPACIÓN

 VINCULOS AFECTIVOS CONFLICTIVOS Y REDES DE COMUNICACIÓN:

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V. HISTORIA PERSONAL:

 INFANCIA:
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 ADOLESCENCIA:
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VI. HISTORIA ESCOLAR:

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VII. OBSERVACIONES: (descripción física, lenguaje no verbal, actitud, etc.)

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VIII. DIMENSIONES:
 COMPORTAMENTAL: ______________________________________________________________________________
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 AFECTIVA: ________________________________________________________________________________________
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 SOMATICA:________________________________________________________________________________________
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 COGNITIVA:_______________________________________________________________________________________
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 SOCIAL: __________________________________________________________________________________________
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IX. PRUEBA Y ANÁLISIS DE RESULTADOS:

 PERSONALIDAD:___________________________________________________________________________________
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 INTELIGENCIA: ____________________________________________________________________________________
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 HABILIDADES:_____________________________________________________________________________________
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 OTRAS:___________________________________________________________________________________________
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X. IMPRESIÓN DIAGNÓSTICA:
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XI. TRATAMIENTO A SEGUIR:

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EVOLUCIÓN

Sesión No. ________ Fecha: ______________________

Objetivo: __________________________________________________________________________________________
__________________________________________________________________________________________________
Descripción: _______________________________________________________________________________________
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Sesión No. ________ Fecha: ______________________

Objetivo: __________________________________________________________________________________________
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Descripción: _______________________________________________________________________________________
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Sesión No. ________ Fecha: ______________________

Objetivo: __________________________________________________________________________________________
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Descripción: _______________________________________________________________________________________
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Sesión No. ________ Fecha: ______________________

Objetivo: __________________________________________________________________________________________
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Descripción: _______________________________________________________________________________________
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Sesión No. ________ Fecha: ______________________

Objetivo: __________________________________________________________________________________________
__________________________________________________________________________________________________
Descripción: _______________________________________________________________________________________
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Sesión No. ________ Fecha: ______________________

Objetivo: __________________________________________________________________________________________
__________________________________________________________________________________________________
Descripción: _______________________________________________________________________________________
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EVALUACIÓN REALIZADA POR: ____________________________________

 CONTROL DE CAMBIOS

FECHA DE
VERSIÓN DESCRIPCIÓN DE CAMBIOS REALIZADOS
APROBACIÓN
- Inclusión de Control de Cambios.
02 Abril 15 de 2009 - Inclusión de página y otros ajustes en el
encabezado.

03 Abril 23 de 2009 - Inclusión de Documento de identidad.