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Transcript of Historia clínica psicológica niños
HISTORIA CLÍNICA PSICOLÓGICA
1. 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………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………....
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........................................................................................................................................................4. ANAMNESIS PERSONAL NORMAL Y PATOLÓGICA
Prenatal:……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….………………………………………………………………………………………………………………………………………………………………….
Natal:…………………………………………………………………………………………………………………………………………………..……………………………………………………………………………………………………………………………………………………………….……………………………………………………………………………………………………………………………………………………………….…
Posnatal:……………………………………………………………………………………………………………………………………………..……………………………………………………………………………………………………………………………………………………………….………………………………………………………………………………………………………………………………………………………………….
Infancia:……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….………………………………………………………………………………………………………………………………………………………………….
5. ANAMNESIS FAMILIAR NORMAL Y PATOLÓGICA………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
6. HISTORIA SOCIAL…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
7. HISTORIA LABORAL……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
8. HISTORIA PSICOSEXUAL……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
9. EXAMEN DE FUNCIONES……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
10. ESTUDIO PSICOLÓGICO……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
11. DIAGNÓSTICO CLÍNICO Y CÓDIGO………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
12. EVOLUCIÓN Y TRATAMIENTO
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13. PRONOSTICO…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
14. FUENTE DE INFORMACIÓN…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
____________________Firma