Código:

ANAMNESIS PSICÓLOGICA
Versión: 1

FECHA DE CONSULTA
Año Mes Día Hora

DATOS GENERALES DEL PACIENTE

Apellidos y Nombres: __________________________________

Documento de identidad: RC____ TI____ CC____
Número de identificación: ______________________________
Edad: _______________________________________________
Fecha de Nacimiento: __________________________________
Lugar de nacimiento: __________________________________
Estado Civil: __________________________________________
Nº de hijos: __________________________________________
Lugar en la familia: ____________________________________
Grado de escolaridad: __________________________________
Ocupación: __________________________________________
Centro de trabajo: ____________________________________
Domicilio: ___________________________________________
Teléfono: ___________________________________________
E-mail: _____________________________________________
Nivel socio-económico: ________________________________
Informante: _________________________________________
Examinador: _________________________________________

MOTIVO DE CONSULTA
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PROBLEMA ACTUAL

• En qué consiste:
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• Desde cuándo (tiempo de aparición):
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• Cómo se le está presentando, ante qué circunstancias, frecuencia:
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• Cómo le afecta al paciente, a la familia, cómo se siente:
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• Qué hace para resolverlo:
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HISTORIA FAMILIAR

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INFANCIA Y NIÑEZ

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EDUCACIÓN O ESCOLARIDAD.

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TRABAJO

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CAMBIOS DE RESIDENCIA

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ACCIDENTES Y ENFERMEDADES

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VIDA SEXUAL

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HÁBITOS E INTERESES.

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ACTITUD FRENTE A LA ENFERMEDAD (TRASTORNO

EMOCIONAL)

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OBSERVACIONES

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