HISTORIA PSICOLOGICA

I. DATOS DE FILIACION
 APELLIDOS Y NOMBRES:______________________________________________________
 EDAD:__________________________ FECHA DE NACIMIENTO:______________________
 LUGAR DE NACIMIENTO:_______________________________ E. CIVIL:_______________
 GRADO DE INSTRUCCIÓN:_____________________________________________________
 DOMICILIO:___________________________________________________________________
 CAMBIOS DOMICILIARIOS (LUGARES):__________________________________________
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 LUGAR DE MAYOR TIEMPO DE RESIDENCIA:____________________________________
 RELIGION:_________________________ OCUPACION:______________________________
 Nº DE HERMANOS:_____________________ LUGARE QUE OCUPA:___________________
 UNIDAD QUE REMITE:__________________________________________________________
 DOCUMENTO:__________________________________________________________________
 LUGAR DE ATENCION:___________________ FECHA:_____________ HORA:____________
 INFORMANTES:_________________________________________________________________
 PSICOLOGOS EVALUADORES: 1) __________________________________________________
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 Fármacos)
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III. HISTORIA PERSONAL
A. ANTECEDENTES PRE Y POST NATAL:
1. EDAD DE LOS PADRES AL NACER EL PACIENTE:
Padre ______ años. Madre ________ años.
2. CONDICIONES DELA MADRE DURANTE LA GESTACION:
Desnutrición ( ), Exceso de trabajo ( ), Problemas Familiares ( ), Amenazas de aborto ( ),
Consumo de drogas ( ), Tabaco ( ), Alcohol ( ), Rayos X ( ), Tuberculosis ( ), Sífilis ( ),
Rubeola ( ), Tiroides ( ), Accidentes ( ), Conflictos ( ), Amplié______________________________
3. PARTO: Tipo de atención ____________________________________Normal ( ), Anormal ( ),
Motivo de este ultimo: ___________________________________________________
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4. NACIMIENTO: _____________ meses, Peso ______________ Talla,____________________
Cianosis o coloración ( ), Anoxia o Asfixia ( ), Planificado ( ), Sexo esperado ( ), Ampliación:
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5. LACTANCIA: Materna ( ), Artificial ( ), Motivo de este ultimo: __________________________
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Edad de destete y reacción: ________________________________________________________
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6. INDEPENDENCIA:
 Locomoción _______________Años, Lenguaje__________________, Asearse ______________
Vestirse _________________ Alimentarse ________________ Control de esfínteres __________
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. SUEÑOS: _______________________________________________________________________
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E. VIDA LABORAL:
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F. VIDA FAMILIAR (Con quien vivió, vive, relaciones familiares)
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 G. CONSUMO DE DROGAS (Alcohol, PBC, etc., Otros)
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H. PERSONALIDAD (¿Cómo 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 económico, 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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