Colegio Santa IsabelDepartamento de Psicología

FICHA PSICOLÓGICA.Datos de Identificación:

- Nombre y Apellido: _______________________________________________________

- Fecha de nacimiento:____/______/20_____- Edad cronológica: ______ años ______ meses ______días. - Sexo: __________________- Nombre del apoderado:___________________________________________________- N° de teléfono: __________________________________________________________- Referido por:____________________________________________________________

Motivo de consulta: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Enfermedad actual: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Examen mental: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Genograma y dinámica familiar:

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Antecedentes familiares médico - psiquiátricos: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Patobiografía: - Antecedentes prenatales:

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- Antecedentes perinatales: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

- Antecedentes postnatales:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

- Desarrollo psicomotor: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

- Desarrollo psicosexual: _________________________________________________

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- Síntomas neuróticos de la infancia: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

- Escolaridad:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

- Historia sexual y de pareja: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

- Historia ocupacional: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

- Personalidad premórbida y vida social: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

- Hábitos psicobiológicos: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Antecedentes personales médicos y psiquiátricos: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Hipótesis Diagnostica: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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EVOLUCIONES: