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Formato de ingreso y anlisis psicolgico clnico

Fecha: Nombre:

Sexo: M H Edad:

Datos de familiares

Nombre: _______________________________________________________________Telfono:______________

Domicilio:_______________________________________________________________

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Observaciones y recomendaciones:

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___Primeras observaciones:

Modo en qe lle!a a consl"a:

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#$econoce qe es"% ocrriendo y en donde se encen"ra& S No

'l"eraciones co!ni"ivas:

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Historial clinico:

Mo"ivos de in!reso:

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O"ros mo"ivos de consl"a:

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Es"ado de %nimo:

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(ondc"as recrren"es:

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(ondc"as a"olesivas: S No De qe "i)o:

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Ti)o de de)endencia:

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Ss"ancias consmidas:

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_Frecencia de consmo:

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*nicio de consmo:______________________________________________________________________________________________

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Mo"ivadores al consmo:

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E"a)a de cambio:

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+rinci)ales mo"ivaciones:

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'"oevalaci,n:

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Enfermedades f-sicas:

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+a"olo!-as dales:

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.reve his"oria familiar:

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Dx )reliminar:

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Dx (ondc"al:

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Sugerencias y observaciones

Es"ilo de aborda/e s!erido:

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Tra"amien"o s!erido:

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$ecomendaciones:

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Evaluacin y tratamiento psicolgico

')licaci,n de )rebas )sicom"ricas:

')licaci,n de )rebas +royec"ivas:

$esl"ados e in"er)re"aciones !enerales:

Modelo de "ra"amien"o y "cnicas a desarrollar:

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Otros diagnstico y gua de codicacin:

F001F02: Tras"ornos men"ales Or!%nicos

F301F32: Tras"ornos men"ales debidos al consmo de ss"ancias )sico"r,)icas

F4014052: Esqi6ofrenias

F44: Tras"ornos de ideas deliran"es )ersis"en"es

F47: Tras"ornos )sic,"icos a!dosF48: Tras"orno de ideas deliran"es indcidas

F70172: Tras"ornos del hmor 9afec"ivos

F73: Tras"orno bi)olar

F74: E)isodios de)resivos

F80: Tras"ornos de ansiedad f,bica

F8350: Tras"orno de )%nico

F8353: Tras"orno de ansiedad !enerali6ada

F8354: Tras"orno mix"o ansioso1de)resivo

F84: Tras"orno obsesivo1com)lsivoF87: $eacciones a es"rs !rave y "ras"ornos de ada)"aci,n

F88: Tras"ornos disocia"ivos 9de conversi,n

F8;: Tras"ornos soma"omorfos

F88: Tras"ornos de la iden"idad sexal

F>;: Tras"ornos de la inclinaci,n sexal

F?01?2: $e"raso men"al

F23: Tras"ornos disociales

F22: Tras"orno men"al sin es)eci@caci,n

O"ros:55555555555555555555555555555555555555555555555555555555555555555555555555555555555555555555555555555555555555555555555555555

Observaciones generales: