UNIVERSIDAD NACIONAL DE TUMBES

FACULTAD DE CIENCIAS SOCIALES

ESCUELA ACADÉMICO PROFESIONAL DE PSICOLOGÍA

HISTORIA CLINICA

I. DATOS DE AFILIACIÓN:

Nombre: _______________________________________________ Sexo: (M) – (F) Edad: _______

Fecha de Nacimiento: _______________________________ Lugar Entre Hermanos: ___________
Lugar de Nacimiento: ___________________ Dpto.: ____________________ Prov.: _______________
Grado de Instrucción: _____________________________ Estado Civil: ( S ) - ( C ) - ( V ) - ( D )
Ocupación: ___________________ Domicilio: __________________________________________________

Ha recibido algún tipo de tratamiento psicológico o psiquiátrico:

_______________________________________________________________________________________________

II. MOTIVO DE CONSULTA

_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

III. DEFINICIÓN DEL PROBLEMA

 EVOLUCIÓN:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
 CAUSA:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
 ACCIONES REALIZADAS EN BUSQUEDA DE SOLUCIÓN
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
 IMPLICACIONES: (a nivel social, familiar, académico, etc)
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

IV. ESTRUCTURA Y FUNCIONALIDAD FAMILIAR:

 FAMILIOGRAMA
MIEMBRO PARENTESCO EDAD ESCOLARIDAD OCUPACIÓN
 UNIVERSIDAD NACIONAL DE TUMBES
FACULTAD DE CIENCIAS SOCIALES
ESCUELA ACADÉMICO PROFESIONAL DE PSICOLOGÍA

 VINCULOS AFECTIVOS CONFLICTIVOS Y REDES DE COMUNICACIÓN:

_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

V. HISTORIA PERSONAL:
 INFANCIA:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
 ADOLECENCIA:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
VI. HISTORIA ESCOLAR:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

VII. OBSERVACIONES: (descripción física, lenguaje no verbal, actitud, etc)

 ANTES:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
 DURANTE:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
 DESPUES:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

VIII. DIMENSIONES:
 COMPORTAMENTAL:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
 AFECTIVA:
 UNIVERSIDAD NACIONAL DE TUMBES
FACULTAD DE CIENCIAS SOCIALES
ESCUELA ACADÉMICO PROFESIONAL DE PSICOLOGÍA
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
 SOMATICA:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
 COGNITIVA:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
 SOCIAL:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
IX. PRUEBA Y ANALISIS DE RESULTADOS:
 PERSONALIDAD:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
 MADUREZ SOCIAL:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
X. IMPRESIÓN DIAGNÓSTICA:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

XI. TRATAMIENTO A SEGUIR:

_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
 RECURSOS SEXOLÓGICOS:
 RECURSOS FARMACOLÓGICOS:

Técnicas para tratar el problema: