HISTORIA PSICOLOGICA

I. DATOS DE FILIACION
APELLIDOS Y
NOMBRES:______________________________________________________
EDAD:__________________________ FECHA DE
NACIMIENTO:______________________
LUGAR DE NACIMIENTO:_______________________________ E.
CIVIL:_______________
GRADO DE
INSTRUCCIN:_____________________________________________________
DOMICILIO:______________________________________________________________
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CAMBIOS DOMICILIARIOS
(LUGARES):__________________________________________
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LUGAR DE MAYOR TIEMPO DE
RESIDENCIA:____________________________________
RELIGION:_________________________
OCUPACION:______________________________
N DE HERMANOS:_____________________ LUGARE QUE
OCUPA:___________________
UNIDAD QUE
REMITE:__________________________________________________________
DOCUMENTO:______________________________________________________
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LUGAR DE ATENCION:___________________ FECHA:_____________
HORA:____________
INFORMANTES:____________________________________________________
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PSICOLOGOS EVALUADORES: 1)
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2) _________________________________________________

OBSERVACION DE CONDUCTA:
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II. MOTIVO DE EVALUACION

FECHA:__________________ HORA:___________________ NOMBRE DEL AUTOR O PRESUNTO
AUTOR:_____________________________________________________________________________
CIRCUNSTANCIAS:___________________________________________________________________
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A. DURACION DE SINTOMAS Y SIGNOS
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B. FACTORES DESENCADENANTES DEL PROBLEMA
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C. REPERCUSIONES DEL PROBLEMA (Nivel: Familiar, Social y Laboral)
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D. TRATAMIENTOS RECIBIDOS (Internamientos y Frmacos)
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III. HISTORIA PERSONAL
A. ANTECEDENTES PRE Y POST NATAL:
1. EDAD DE LOS PADRES AL NACER EL PACIENTE:
Padre ______ aos. Madre ________ aos.
2. CONDICIONES DELA MADRE DURANTE LA GESTACION:
Desnutricin ( ), Exceso de trabajo ( ), Problemas Familiares ( ), Amenazas de aborto ( ),
Consumo de drogas ( ), Tabaco ( ), Alcohol ( ), Rayos X ( ), Tuberculosis ( ), Sfilis ( ),
Rubeola ( ), Tiroides ( ), Accidentes ( ), Conflictos ( ), Ampli______________________________
3. PARTO: Tipo de atencin ____________________________________Normal
( ), Anormal ( ),
Motivo de este ultimo: ___________________________________________________
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4. NACIMIENTO: _____________ meses, Peso ______________
Talla,____________________
Cianosis o coloracin ( ), Anoxia o Asfixia ( ), Planificado ( ), Sexo esperado ( ), Ampliacin:
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5. LACTANCIA: Materna ( ), Artificial ( ), Motivo de este ultimo:
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Edad de destete y reaccin: ________________________________________________________
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6. INDEPENDENCIA:
Locomocin _______________Aos, Lenguaje__________________, Asearse ______________
Vestirse _________________ Alimentarse ________________ Control de esfnteres __________
7. ENFERMEDADES:
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8. ACCIDENTES:
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9. OPERACIONES:
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B. ESCOLARIDAD
INICIAL : EDAD _______________ COLEGIO
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PRIMARIA: EDAD _______________ COLEGIO:
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SECUNDARIA: EDAD ______________ COLEGIO:
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SUPERIOS: EDAD:
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C. VIDA SEXUAL:
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D. SUEOS:
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E. VIDA LABORAL:
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 F. VIDA FAMILIAR (Con quien vivi, vive, relaciones familiares)
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G. CONSUMO DE DROGAS (Alcohol, PBC, etc., Otros)
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H. PERSONALIDAD (Cmo se describe?)

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I. ANTECEDENTES POLICIALES Y/O JUDICIALES:
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IV. HISTORIA FAMILIAR

PADRE: _________________________________ MADRE: __________________________________
PADRASTRO:____________________________ MADRASTRA:_____________________________
ABUELO (A) MATERNO:_____________________________________________________________
ABUELO (A) PATERNO:______________________________________________________________
HERMANOS:
1. ______________________________________________________________________________
2. ______________________________________________________________________________
3. ______________________________________________________________________________
4. ______________________________________________________________________________
5. ______________________________________________________________________________
6. ______________________________________________________________________________
7. ______________________________________________________________________________
8. ______________________________________________________________________________

SITUACION SOCIO-ECONOMICA Y FAMILIAR (Quien sostienen el hogar, ingreso econmico, tipo

de vivienda, numero de habitaciones, habitantes, pertenece a un club)
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ANTECEDENTES PSICOPATOLOGICOS (Familiares por parte de de Padre o Madre)
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