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Transcript of FBE.70.doc
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:
______________________________________________________________________________________
ll. MOTIVO DE CONSULTA:
__________________________________________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________lll. DEFINICIN DEL PROBLEMA:
EVOLUCIN:______________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________
CAUSAS:__________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
ACCIONES REALIZADAS EN BUSCA DE SOLUCIN: ______________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________
IMPLICACIONES: (a nivel familiar, social, acadmico, etc.): ____________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________
lV. ESTRUCTURA Y FUNCIONALIDAD FAMILIAR:
FAMILIOGRAMA:
MIEMBROPARENTESCOEDADESCOLARIDADOCUPACIN
VINCULOS AFECTIVOS CONFLICTIVOS Y REDES DE COMUNICACIN:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
V. HISTORIA PERSONAL:
INFANCIA: __________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
ADOLESCENCIA:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
VI. HISTORIA ESCOLAR:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
VII. OBSERVACIONES: (descripcin fsica, lenguaje no verbal, actitud, etc.)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
VIII. DIMENSIONES:
COMPORTAMENTAL: ________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________ AFECTIVA: __________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________ SOMATICA:__________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________
COGNITIVA:_________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________ SOCIAL: ____________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________
IX. PRUEBA Y ANLISIS DE RESULTADOS:
PERSONALIDAD:_____________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
INTELIGENCIA: ______________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
HABILIDADES:_______________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
OTRAS:_____________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
X. IMPRESIN DIAGNSTICA:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
XI. TRATAMIENTO A SEGUIR:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
EVOLUCIN
Sesin No. ________ Fecha: ______________________
Objetivo: ____________________________________________________________________________________________________________________________________________________________________________________________
Descripcin: _______________________________________________________________________________________
__________________________________________________________________________________________________
Sesin No. ________ Fecha: ______________________
Objetivo: __________________________________________________________________________________________
__________________________________________________________________________________________________
Descripcin: _______________________________________________________________________________________
__________________________________________________________________________________________________
Sesin No. ________ Fecha: ______________________
Objetivo: __________________________________________________________________________________________
__________________________________________________________________________________________________
Descripcin: _______________________________________________________________________________________
__________________________________________________________________________________________________
Sesin No. ________ Fecha: ______________________
Objetivo: __________________________________________________________________________________________
__________________________________________________________________________________________________
Descripcin: _______________________________________________________________________________________
__________________________________________________________________________________________________
Sesin No. ________ Fecha: ______________________
Objetivo: __________________________________________________________________________________________
__________________________________________________________________________________________________
Descripcin: _______________________________________________________________________________________
__________________________________________________________________________________________________
Sesin No. ________ Fecha: ______________________
Objetivo: __________________________________________________________________________________________
__________________________________________________________________________________________________
Descripcin: _______________________________________________________________________________________
__________________________________________________________________________________________________
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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