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UNIVERIDAD UCENM
FACULTAD DE PSICOLOGIA
LIC. PSICOLOGIA
1. DATOS PERSONALES
 Nombre: ______________________________________________________________
 Lugar de nacimiento: ____________________________________________________
 Edad: __________________ Estado civil: ______________
 Ocupaci坦n: _____________________________ Sexo: ___________________
 Nivel Escolaridad: ______________________________________________________
 Religi坦n: ______________________________________________________________
 Datos de los progenitores: ________________________________________________
 Nombre de la Madre: ____________________________________________________
 Residencia: ___________________________________________________________
 Procedencia: __________________________________________________________
 Nombre de la Padre: ____________________________________________________
 Residencia: ___________________________________________________________
 Procedencia: __________________________________________________________
2. MOTIVO DE CONSULTA: ___________________________________________________
________________________________________________________________________
________________________________________________________________________
_________________________________ __________________________________
FIRMA DEL RESPONSABLE FIRMA DEL PASANTE DE CARRERA
DE PSICOLOGIA
SESION FECHA ACTIVIDAD
2. MOTIVO DE CONSULTA: ___________________________________________________
________________________________________________________________________
________________________________________________________________________
3. HISTORIA DE LA ENFERMEDAD: _____________________________________________
_________________________________________________________________________
4. ANAMNESIS PERSONAL Y PATOLOGICA
 Prenatal: ____________________________________________________________
____________________________________________________________
 Natal: _______________________________________________________________
_______________________________________________________________
 Posnatal: ____________________________________________________________
____________________________________________________________
 Infancia: ____________________________________________________________
____________________________________________________________
5. ANAMNESIS FAMILIAR NORMAL Y PATOLOGIA
___________________________________________________________________________
___________________________________________________________________________
6. HISTORIA SOCIAL
___________________________________________________________________________
___________________________________________________________________________
7. HISTORIA LABORAL
___________________________________________________________________________
___________________________________________________________________________
8. HISTORIA PSICOSEXUAL
___________________________________________________________________________
___________________________________________________________________________
9. EXAMENES DE FUNCIONES
___________________________________________________________________________
___________________________________________________________________________
10.ESTUDIOS PSICOLOGICO
___________________________________________________________________________
___________________________________________________________________________
11. DIAGNOSTICO CLINICO Y CODIGO
___________________________________________________________________________
___________________________________________________________________________
12.EVOLUCION Y TRATAMIENTO
___________________________________________________________________________
13.PRONOSTICO____________________________________________________________
___________________________________________________________________________
14. FUENTE DE INFORMACION
___________________________________________________________________________
___________________________________________________________________________
_________________________________ __________________________________
FIRMA DEL RESPONSABLE FIRMA DEL PASANTE DE CARRERA
DE PSICOLOGIA

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Ficha clinica odily

  • 1. UNIVERIDAD UCENM FACULTAD DE PSICOLOGIA LIC. PSICOLOGIA 1. DATOS PERSONALES Nombre: ______________________________________________________________ Lugar de nacimiento: ____________________________________________________ Edad: __________________ Estado civil: ______________ Ocupaci坦n: _____________________________ Sexo: ___________________ Nivel Escolaridad: ______________________________________________________ Religi坦n: ______________________________________________________________ Datos de los progenitores: ________________________________________________ Nombre de la Madre: ____________________________________________________ Residencia: ___________________________________________________________ Procedencia: __________________________________________________________ Nombre de la Padre: ____________________________________________________ Residencia: ___________________________________________________________ Procedencia: __________________________________________________________ 2. MOTIVO DE CONSULTA: ___________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _________________________________ __________________________________ FIRMA DEL RESPONSABLE FIRMA DEL PASANTE DE CARRERA DE PSICOLOGIA SESION FECHA ACTIVIDAD
  • 2. 2. MOTIVO DE CONSULTA: ___________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 3. HISTORIA DE LA ENFERMEDAD: _____________________________________________ _________________________________________________________________________ 4. ANAMNESIS PERSONAL Y PATOLOGICA Prenatal: ____________________________________________________________ ____________________________________________________________ Natal: _______________________________________________________________ _______________________________________________________________ Posnatal: ____________________________________________________________ ____________________________________________________________ Infancia: ____________________________________________________________ ____________________________________________________________ 5. ANAMNESIS FAMILIAR NORMAL Y PATOLOGIA ___________________________________________________________________________ ___________________________________________________________________________ 6. HISTORIA SOCIAL ___________________________________________________________________________ ___________________________________________________________________________ 7. HISTORIA LABORAL ___________________________________________________________________________ ___________________________________________________________________________ 8. HISTORIA PSICOSEXUAL ___________________________________________________________________________ ___________________________________________________________________________ 9. EXAMENES DE FUNCIONES ___________________________________________________________________________ ___________________________________________________________________________ 10.ESTUDIOS PSICOLOGICO
  • 3. ___________________________________________________________________________ ___________________________________________________________________________ 11. DIAGNOSTICO CLINICO Y CODIGO ___________________________________________________________________________ ___________________________________________________________________________ 12.EVOLUCION Y TRATAMIENTO ___________________________________________________________________________ 13.PRONOSTICO____________________________________________________________ ___________________________________________________________________________ 14. FUENTE DE INFORMACION ___________________________________________________________________________ ___________________________________________________________________________ _________________________________ __________________________________ FIRMA DEL RESPONSABLE FIRMA DEL PASANTE DE CARRERA DE PSICOLOGIA