HISTORIA CLINICA

PROCESO BIENESTAR ESTUDIANTIL

SUBPROCESO ATENCIN EN SALUDCdigo: FBE.70

Versin: 03

HISTORIA CLNICA DE PSICOLOGA

Pgina 1 de 4

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:_______________________ Cdigo:_______________ Semestre:___________ Nivel:________

Crditos cursados: ____________ Crditos Aprobados: ____________

Promedio Acumulado: ________ Promedio del Semestre Anterior: _______

Direccin actual:________________________________________________________________________Telfono: _____________

Direccin de la Familia: _____________________________________ Ciudad:____________________Telfono: _______________

Ha recibido algn tipo de tratamiento psicolgico o psiquitrico:

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ll. MOTIVO DE CONSULTA:

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__________________________________________________________________________________________________________________________________________________________________________________________________________lll. DEFINICIN DEL PROBLEMA:

EVOLUCIN:______________________________________________________________________________________

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CAUSAS:__________________________________________________________________________________________

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ACCIONES REALIZADAS EN BUSCA DE SOLUCIN: ______________________________________________________________________________________________________________________________________________________

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IMPLICACIONES: (a nivel familiar, social, acadmico, etc.): ____________________________________________________________________________________________________________________________________________________

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lV. ESTRUCTURA Y FUNCIONALIDAD FAMILIAR:

FAMILIOGRAMA:

MIEMBROPARENTESCOEDADESCOLARIDADOCUPACIN

VINCULOS AFECTIVOS CONFLICTIVOS Y REDES DE COMUNICACIN:

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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: (descripcin fsica, lenguaje no verbal, actitud, etc.)

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VIII. DIMENSIONES:

COMPORTAMENTAL: ________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________ AFECTIVA: __________________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________ SOMATICA:__________________________________________________________________________________________________________________________________________________________________________________________

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COGNITIVA:_________________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________ SOCIAL: ____________________________________________________________________________________________________________________________________________________________________________________________

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IX. PRUEBA Y ANLISIS DE RESULTADOS:

PERSONALIDAD:_____________________________________________________________________________________________________________________________________________________________________________________

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INTELIGENCIA: ______________________________________________________________________________________________________________________________________________________________________________________

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HABILIDADES:_______________________________________________________________________________________________________________________________________________________________________________________

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OTRAS:_____________________________________________________________________________________________________________________________________________________________________________________________

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X. IMPRESIN DIAGNSTICA:

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XI. TRATAMIENTO A SEGUIR:

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EVOLUCIN

Sesin No. ________ Fecha: ______________________

Objetivo: ____________________________________________________________________________________________________________________________________________________________________________________________

Descripcin: _______________________________________________________________________________________

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Sesin No. ________ Fecha: ______________________

Objetivo: __________________________________________________________________________________________

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Descripcin: _______________________________________________________________________________________

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Sesin No. ________ Fecha: ______________________

Objetivo: __________________________________________________________________________________________

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Descripcin: _______________________________________________________________________________________

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Sesin No. ________ Fecha: ______________________

Objetivo: __________________________________________________________________________________________

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Descripcin: _______________________________________________________________________________________

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Sesin No. ________ Fecha: ______________________

Objetivo: __________________________________________________________________________________________

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Descripcin: _______________________________________________________________________________________

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Sesin No. ________ Fecha: ______________________

Objetivo: __________________________________________________________________________________________

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Descripcin: _______________________________________________________________________________________

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EVALUACIN REALIZADA POR: ____________________________________CONTROL DE CAMBIOS

VERSINFECHA DE APROBACINDESCRIPCIN DE CAMBIOS REALIZADOS

02Abril 15 de 2009- Inclusin de Control de Cambios.

- Inclusin de pgina y otros ajustes en el encabezado.

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

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