HISTORIA CLINICAMODELO DE ENTREVISTA INICIAL

ERNESTO PÉREZ LÓPEZENTREVISTA

UNIVERSIDAD ANÁHUAC MÉXICO NORTE - ISEF SEDE MÉXICO

NOVIEMBRE 2015

l. DATOS PERSONALES

No. Historia:____________ Fecha:_____________

Nombres:________________________________________ Apellidos:______________________________ Edad:______________ Sexo:__________ Estado Civil:______________Lugar y fecha deNacimiento:____________________________________________________________________________Carrera:_______________________ Semestre:___________ Nivel:______________ Semestres/años cursados: ____________ Promedio Actual: ________ Promedio del Semestre/año Anterior: _______Dirección actual:________________________________________________________________________

Dirección de la Familia:________________________________________________________ Ciudad:____________________

Teléfono (casa): _______________ Teléfono (celular): _______________

Ha recibido algún tipo de tratamiento psicológico o psiquiátrico, ¿por qué?:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Hace cuánto tiempo:_____________________________________

ll. MOTIVO DE CONSULTA:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________lll. DEFINICIÓN DEL PROBLEMA:

EVOLUCIÓN:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

CAUSAS:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

ACCIONES REALIZADAS EN BUSCA DE SOLUCIÓN: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

ERNESTO PÉREZ LÓPEZ

IMPLICACIONES: (a nivel familiar, social, académico, etc.): ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

lV. ESTRUCTURA Y FUNCIONALIDAD FAMILIAR:

FAMILIOGRAMA:

MIEMBRO PARENTESCO EDAD ESCOLARIDAD OCUPACIÓN

VINCULOS AFECTIVOS CONFLICTIVOS Y REDES DE COMUNICACIÓN:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

V. HISTORIA PERSONAL:

INFANCIA: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

ADOLESCENCIA: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

VI. HISTORIA ESCOLAR:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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

ERNESTO PÉREZ LÓPEZ

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

VIII. DIMENSIONES:

COMPORTAMENTAL: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

AFECTIVA: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SOMATICA:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

COGNITIVA:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SOCIAL: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

IX. PRUEBA Y ANÁLISIS DE RESULTADOS:

PERSONALIDAD:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

INTELIGENCIA: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HABILIDADES:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

OTRAS:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

X. IMPRESIÓN DIAGNÓSTICA:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

ERNESTO PÉREZ LÓPEZ

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

XI. TRATAMIENTO A SEGUIR:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

EVOLUCIÓN Y SEGUIMIENTO

Sesión No. ________ Fecha: ______________________Objetivo: ____________________________________________________________________________________________________________________________________________________________________________________________Descripción: _________________________________________________________________________________________________________________________________________________________________________________________

Sesión No. ________ Fecha: ______________________Objetivo: ____________________________________________________________________________________________________________________________________________________________________________________________Descripción: _________________________________________________________________________________________________________________________________________________________________________________________

Sesión No. ________ Fecha: ______________________Objetivo: ____________________________________________________________________________________________________________________________________________________________________________________________Descripción: _________________________________________________________________________________________________________________________________________________________________________________________

Sesión No. ________ Fecha: ______________________Objetivo: ____________________________________________________________________________________________________________________________________________________________________________________________Descripción: _________________________________________________________________________________________________________________________________________________________________________________________

EVALUACIÓN REALIZADA POR:

____________________________________

ERNESTO PÉREZ LÓPEZ