Universidad Mariano Gálvez

Facultad de Psicología
Ficha Clínica
1. Datos Generales:

Nombre completo y apellidos: ____________________________________________________

Edad: ____________________________________Sexo: ______________________________
Dirección: ___________________________________________________________________
Teléfono: ____________________________________________________________________
Número de hermanos: ___________Lugar que ocupa entre sus hermanos: ________________
Estado civil: _________________________ Religión: _________________________________
Trabajo actual y/o ocupación y/o estudio: ___________________________________________
Otras actividades: _____________________________________________________________
Nombre del esposo/a: __________________________________________________________
Escolaridad del esposo/a: _______________________________________________________
Tiene hijos: ______________________________Cuantos:_____________________________
Nombres y edades:
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Escolaridad: _________________________ Ha repetido algún grado: ___________________
Nombre de la padre: _________________________________ Edad: ____________________
Ocupación: __________________________________________________________________
Nombre de la madre: _________________________________ Edad: ____________________
Ocupación: __________________________________________________________________
Fechas de la entrevista: ________________________________________________________

2. Motivo de consulta:
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 3. Historia del problema actual:

Factores precipitantes, duración del problema, impacto familiar.

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Antecedentes
PATOLÓGICOS NO PATOLÓGICOS

4. Historia familiar:

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 5. Genograma:

6. Examen Mental:

Dinámica Emocional y Conductual:

Estable Hiperactividad psicomotora

Cooperador Indiferencia
Cambios emocionales Ansiedad
Labilidad emocional Depresión (leve, moderado, profunda)
Llanto reflejo
Apariencia física: _____________________________________________________________
Apariencia personal: ___________________________________________________________
Conducta: ___________________________________________________________________
Estado de ánimo: _____________________________________________________________

Funciones Cognoscitivas:

Estado de conciencias: Orientación: Atención y/o concentración

Alerta Persona Funcional Con esfuerzo
Obnulación Tiempo Concentrada Lábil
Confusión Espacio Hace asociaciones Fatigada
Somnolencia Situación Sigue indicaciones Negligencia

Memoria: Lenguaje Pensamiento

Inmediata Estructurado Concreto
Reciente Ininteligible Abstracto
Remota Disritmico Lógico
Visual Dificultad de nominación Buen contacto con la realidad
Verbal Déficit Auditivo Sigue indicaciones

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7. Pruebas psicométricas aplicadas:
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8. Criterios diagnósticos:

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9. Evaluación Multiaxial:

Eje I:
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Eje II:
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Eje III:
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Eje IV:
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Eje V:
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10. Pronóstico:
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11. Plan de tratamiento:

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12. Notas de evolución:

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13. Observaciones:

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Nombre del estudiante responsable
No. de carné