HISTORIA PSICOLÓGICA PARA NIÑOS Y ADOLESCENTES FECHA:__________________________ NOMBRE
Y
APELLIDOS:_____________________________________________________________________________ ____________ FECHA Y LUGAR DE NAC:________________________________________EDAD:____________ SEXO: F_________ M___________ NIVEL
DE
LA
ESCOLARIDAD:_________________________________________________RELIGIÓN:________________ ___________ CENTRO EDUCATIVO:_____________________________________________________________________________ ______________ NOMBRES
Y
APELLIDOS
DE
LA
MADRE:___________________________________________________________________________ EDAD:
________
CÉDULA
DE
IDENTIDAD:______________________INSTRUCCIÓN:_______________________________________ OCUPACIÓN: ________________________________________________________________________________________ __________ NOMBRE
DEL
PADRE:_________________________________________________________________________________ __________ EDAD:
________
CÉDULA
DE
IDENTIDAD:______________________INSTRUCCIÓN:_______________________________________ OCUPACIÓN:____________________________________________________________________________ ______________________ CON
QUIEN
VIVE:
________________________________________________________________________________________ ______ NRO
DE
TELÉFONO:
HABITACIONAL:_________________________________MÓVIL:__________________________________ ____ GENOGRAMA
ANTECEDENTES SIGNIFICATIVOS:_________________________________________________________________________ _______ ________________________________________________________________________________________ ______________________ ________________________________________________________________________________________ ______________________ ________________________________________________________________________________________ ______________________ ENFERMEDAD ACTUAL:________________________________________________________________________________ _________ ________________________________________________________________________________________ ______________________ FÁRMACOS:_____________________________________________________________________________ ________________________________________________________________________________________ ____________________________________________ HA
RECIBIDO
ATENCIÓN
PSICOLÓGICA
ANTERIORMENTE:___________________________________________________________ CAUSA:_________________________________________________________________________________ ______________________ MOTIVO
DE
CONSULTA:_____________________________________________________________________________ ____________ ________________________________________________________________________________________ ______________________ ________________________________________________________________________________________ ______________________ HISTORIA PERSONAL:_____________________________________________________________________________ _____________ ________________________________________________________________________________________ ______________________ ________________________________________________________________________________________ ______________________ ________________________________________________________________________________________ ______________________ ________________________________________________________________________________________ ______________________
________________________________________________________________________________________ ______________________ ________________________________________________________________________________________ ______________________ ________________________________________________________________________________________ ______________________ ________________________________________________________________________________________ ______________________ ________________________________________________________________________________________ ______________________ ________________________________________________________________________________________ ______________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ______________________ OBJETIVOS
DEL
TRATAMIENTO:__________________________________________________________________________ ________ ________________________________________________________________________________________ ______________________ ________________________________________________________________________________________ ______________________ ________________________________________________________________________________________ ______________________ EVOLUCIÓN:____________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________
________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ _____________________________________________