Ficha Clínica Plan de Tratamiento Integral de Adicción y Drogodependencia.

I. Datos Generales: Nombre Completo:_______________________________________________

Nº Ficha: __________________________

RUT: _____________________________

Edad:_____________________________

Escolaridad: _______________________

Estado Civil: ________________________

Domicilio: ______________________________________

Ocupación: _____________________________________

Teléfonos: ______________________________________

Origen Derivación: _________________________________________________

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Motivo Consulta: __________________________________________________

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II. Cuadro clínico actual:

Sintomatología actual: ______________________________________________

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Inicio: ___________________________________________________________

Tratamientos anteriores: ____________________________________________

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Evolución:

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III. Antecedentes Psiquiátricos:

Tipo de cuadro o diagnóstico: ________________________________________

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Duración: ________________________________________________________

Tratamientos farmacológicos previos: _________________________________

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Internaciones previas: ______________________________________________

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IV. Antecedentes Mórbidos:

HTA: ____________________________________________________________

Endocrinos: ______________________________________________________

Gastrointestinal: __________________________________________________

Neurológicos: _____________________________________________________

Traumatismos: ____________________________________________________

Otros: ___________________________________________________________

V. Antecedentes de intentos de Suicidio:

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VI. Antecedentes psicosociales familiares:

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VII. Genograma:

VIII. Examen mental:

Conciencia:_______________________________________________________

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Psicomotilidad:____________________________________________________

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Afectividad:_______________________________________________________

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Lenguaje:_________________________________________________________

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Pensamiento:_____________________________________________________

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Sensopercepción:__________________________________________________

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Inteligencia:______________________________________________________

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IX. Historia de Abuso de sustancias:

Tipo de sustancias:_________________________________________________

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Antecedentes Familiares de consumo__________________________________

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X. Diagnósticos DSM IV-R:

Eje I:____________________________________________________________

Eje II:____________________________________________________________

Eje III:___________________________________________________________

Eje IV:___________________________________________________________

Eje V:____________________________________________________________

XI. Conciencia de enfermedad y nivel motivacional:

1.-______________________________________________________________

2.-______________________________________________________________

XII. Puntajes Test psicológicos:

Personalidad:_____________________________________________________

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Suicidalidad:______________________________________________________

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OQ 45.2:_________________________________________________________

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Craving:__________________________________________________________

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XIII. Plan de tratamiento:

Psiquiátrico/

farmacológico_____________________________________________________

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Piscoterapéutico___________________________________________________

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Intervención Familiar_______________________________________________

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Intervenciones Grupales____________________________________________

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Psicoeducación____________________________________________________

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