ENTREVISTA PSICOLGICA

I- INFORMACIN GENERAL

Nombre del Evaluado (a): ________________________________________________________

Nombre de la Madre: ___________________________________________________________
Nombre del Padre: _____________________________________________________________
Edad: ___________________________________
Sexo: ___________________________________
Fecha de Nacimiento: ___________________________________________________________
Escolaridad: ___________________________________________________________________
Direccin: ____________________________________________________________________
Telfono: _______________________________

II- MOTIVO DE LA ATENCIN:

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________

III- HISTORIA PERSONAL:

- Ambiente Familiar:
-Familia de Origen (relacin con: padre, madre, hermanos, abuelos, otros).
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________
-Ambiente Conyugal:
-Unido(a), casado(a), divorciado(a), hijos, nmero de uniones, otros).
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________
-Ambiente Social
-Relacin con el grupo amistades, empleo del tiempo libre, actividades que realiza
(fiestas, clubes deportivos).
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________
-Ambiente Laboral
-Fuente de ingreso, donde labora, empleos previos.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________
-Ambiente Escolar:
-Historia del desempeo escolar durante la primaria y secundaria, desercin
escolar, peleas, pandillas, ausentismo.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________

F- HBITOS Y COSTUMBRES

Cigarrillos

 Alcohol
Drogas (especifique cul)
Conducta antisocial (Infancia, adolescencia y adultez
Conducta Sexual
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________

IV- ANTECEDENTES PATOLGICOS PERSONALES:

1. Enfermedad Actual
2. Hospitalizaciones y Cirugas
3. Enfermedad Mental
4. Enfermedades Hereditarias
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________
Familiares
1. Enfermedad Mental
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________

V- OBSERVACIONES:

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________

ENTREVISTA PSICOLGICA
I- INFORMACIN GENERAL

Nombre del Evaluado (a): ________________________________________________________

Nombre de la Madre: ___________________________________________________________

Nombre del Padre: _____________________________________________________________

Edad: ___________________________________
Sexo: ___________________________________
Fecha de Nacimiento: ___________________________________________________________
Escolaridad: ___________________________________________________________________
Direccin: ____________________________________________________________________
Telfono: _______________________________

II- MOTIVO DE LA ATENCIN:

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________

III- HISTORIA PERSONAL:

- Ambiente Familiar:
-Familia de Origen (relacin con: padre, madre, hermanos, abuelos, otros).
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________
-Ambiente Conyugal:
-Unido(a), casado(a), divorciado(a), hijos, nmero de uniones, otros).
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________
-Ambiente Social
-Relacin con el grupo amistades, empleo del tiempo libre, actividades que realiza
(fiestas, clubes deportivos).
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________
-Ambiente Laboral
-Fuente de ingreso, donde labora, empleos previos.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________
-Ambiente Escolar:
-Historia del desempeo escolar durante la primaria y secundaria, desercin
escolar, peleas, pandillas, ausentismo.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________

F- HBITOS Y COSTUMBRES

Cigarrillos
Alcohol
Drogas (especifique cul)
Conducta antisocial (Infancia, adolescencia y adultez

 Conducta Sexual
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________

IV- ANTECEDENTES PATOLGICOS PERSONALES:

5. Enfermedad Actual
6. Hospitalizaciones y Cirugas
7. Enfermedad Mental
8. Enfermedades Hereditarias
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________
Familiares
2. Enfermedad Mental
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________

V- OBSERVACIONES:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________

ENTREVISTA PSICOLGICA
I- DATOS GENERALES:
Nombres y Apellidos: _________________________________________________________
Fecha de Nacimiento: _________________________________________________________
Edad Cronolgica exacta: ______________________________________________________
Sexo: _______________________________________

Trabajo/ Universidad:
__________________________________________________________________________________
____________________________________________________________________
Lugar del Examen: ____________________________________________________________
Direccin: ___________________________________________________________________
Telfono: ____________________________________
II- MOTIVO DE CONSULTA:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
______________________________________________________
III- DESCRIPCIN GENERAL:
Vestimenta: ___________________________________________________________
_____________________________________________________________________
Postura: ______________________________________________________________
_____________________________________________________________________
Expresin Verbal: _______________________________________________________
_____________________________________________________________________
Actitud: _______________________________________________________________
_____________________________________________________________________
Estado General de nimo: ________________________________________________
_____________________________________________________________________
Emotividad: ___________________________________________________________
IV- HISTORIA PERSONAL
1. Antecedentes antes del Nacimiento:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
______________________________________________________
2-Antescedentes despus del Nacimiento:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
______________________________________________________
V- ANTESCEDENTES FAMILIARES:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
______________________________________________________
VI- ANTESCEDENTES ESCOLARES:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
______________________________________________________
VII-OBSERVACIONES:
__________________________________________________________________________________
__________________________________________________________________________________

__________________________________________________________________________________
______________________________________________________
VIII- RECOMENDACIONES:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
______________________________________________________

ENTREVISTA PSICOLGICA
I- DATOS GENERALES:
Nombres y Apellidos: _________________________________________________________
Fecha de Nacimiento: _________________________________________________________
Edad Cronolgica exacta: ______________________________________________________
Sexo: _______________________________________
Trabajo/ Universidad:
__________________________________________________________________________________
____________________________________________________________________
Lugar del Examen: ____________________________________________________________
Direccin: ___________________________________________________________________
Telfono: ____________________________________
II- MOTIVO DE CONSULTA:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
______________________________________________________
III- DESCRIPCIN GENERAL:
Vestimenta: ___________________________________________________________
_____________________________________________________________________
Postura: ______________________________________________________________
_____________________________________________________________________
Expresin Verbal: _______________________________________________________
_____________________________________________________________________
Actitud: _______________________________________________________________
_____________________________________________________________________
Estado General de nimo: ________________________________________________
_____________________________________________________________________
Emotividad: ___________________________________________________________
IV- HISTORIA PERSONAL
1. Antecedentes antes del Nacimiento:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
______________________________________________________
2-Antescedentes despus del Nacimiento:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
______________________________________________________
V- ANTESCEDENTES FAMILIARES:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
______________________________________________________
VI- ANTESCEDENTES ESCOLARES:

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
______________________________________________________
VII-OBSERVACIONES:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
______________________________________________________
VIII- RECOMENDACIONES:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
______________________________________________________