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Historia clínica psicológica niños

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Historia clínica psicológica niños

  1. 1. HISTORIA CLÍNICA PSICOLÓGICA1. 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. 2. ........................................................................................................................................................................... ........................................................................................................................................................................... ........................................................................................................................................................................... ........................................................................................................................................................4. ANAMNESIS PERSONAL NORMAL Y PATOLÓGICA Prenatal:………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………….… ………………………………………………………………………………………………………………………………………………………………. Natal:…………………………………………………………………………………………………………………………………………………..… …………………………………………………………………………………………………………………………………………………………….… …………………………………………………………………………………………………………………………………………………………….… Posnatal:……………………………………………………………………………………………………………………………………………..… …………………………………………………………………………………………………………………………………………………………….… ………………………………………………………………………………………………………………………………………………………………. Infancia:………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………….… ……………………………………………………………………………………………………………………………………………………………….5. ANAMNESIS FAMILIAR NORMAL Y PATOLÓGICA …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………6. HISTORIA SOCIAL …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………7. HISTORIA LABORAL …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………
  3. 3. …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………8. HISTORIA PSICOSEXUAL …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………9. EXAMEN DE FUNCIONES …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………10. ESTUDIO PSICOLÓGICO …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………11. DIAGNÓSTICO CLÍNICO Y CÓDIGO …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………12. EVOLUCIÓN Y TRATAMIENTO …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………
  4. 4. …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………13. PRONOSTICO …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………14. FUENTE DE INFORMACIÓN …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………… ____________________ Firma

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