Documente Academic
Documente Profesional
Documente Cultură
A. Ficha de identificacin.
Expediente no.
Nombre:______________________________________________________
Edad: ______________ Sexo________ Estado civil___________________
Fecha de Nacimiento ____________ Originario
de:____________________
Direccin:_____________________________________________________
Telfonos: casa___________________ trabajo_______________________
Ocupacin:____________________ Puesto _________________________
Escuela ______________________ Escolaridad mxima:_______________
Nivel socioeconmico: ________________ Religin: __________________
Persona o institucin que lo
refiere:________________________________
Nombre del responsable legal:
____________________________________
Fuente de informacin:__________________________________________
Fecha de elaboracin____________________________________________
B. Motivo de consulta.
Acude de manera: ( voluntaria, involuntaria, forzada,
condicionada )
Por presentar: (anotar textualmente lo referido por el paciente):
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Padecimiento actual. Cuadro clnico. caracterizado
por:______________
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Que inicia aproximadamente en: (fecha)
____________________________ De manera: (sbita, insidiosa,
incierta ) ___________________________
De caractersticas:(intenso, leve, moderado, variable, recurrente,
permanente) _________________________________________________
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Aparentemente desencadenado por:
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Accidentes: (descripcin y consecuencias):
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Cirugas: (descripcin): __________________________________________
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Perfil ginecolgico (menarca, dismenorrea, gesta, para, etc.)
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Sexualidad. (inicio, actitud, conflictiva, satisfaccin)
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Antecedentes familiares.
Familiares con trastornos del comportamiento:
parentesco______________
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Familiares con padecimientos crnicos:
parentesco____________________
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5. Dinmica familiar
Tipo de relacin entre los miembros de la familia nuclear:
Dependiente Independient Oposicionista Cooperadora
Agresiva
Devualuatoria
Displiscente
Voluble
Afectuosa
e
Cordial
Reforzadora
Emptica
Consistente
Inexpresiva
Intrusiva
Explotadora
Rgida
Pasiva
Jerarquizada
Respetuosa
Generosa
Flexible
Participativa
Desorganizada.
Familiograma:
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Descripcin____________________________________________________
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desempeo acadmico __________________________________________
reprobacin __________________________ promedio ________________
Eventos significativos: (separaciones, prdidas objetales, cambios
de estatus, cambio de domicilio, muertes, etc.)
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Historia laboral: (desempeo, productividad, ascensos, despidos,
conflictos con la autoridad, ausentismo, conflictiva interpersonal,
etc.)_____________
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G.Examen mental.
Aspecto: (alio: bueno, regular, malo.)
(higiene)._____________________
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Disposicin: (buena, mala). ______________________________________
Conducta motora: (normal, anormal, disminuda, aumentada,
congruente, incongruente,
etc.)______________________________________________
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Marcha: ______________________________________________________
Saludo: (cordial, tenso, agresivo, respetuoso, ausente, sincero,
obligado, etc.)
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Contacto visual: (adecuado, inadecuado, evasivo, retador, fijo,
variable, etc.)
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Estilo de vestimenta: (adecuado, inadecuado; caractersticas)
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Accesorios: (ausentes, escasos, excesivos, adecuados,
inadecuados)______
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Facies: (depresiva, ansiosa, inexpresiva, neurolgica,
etc.)______________
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Lenguaje: (tono de voz, coherencia, congruencia, espontaneidad,
sinceridad, fluidez, amplitud, direccionalidad, claridad, amenidad,
tipos de contenido (describirlos), suspicacias, cinrcunloquios,
muletillas, neologismos, modismos, jerga, pararespuestas, etc.
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Orientacin en tiempo lugar y espacio:
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Alteraciones
sensoperceptuales____________________________________
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Funciones mentales superiores: (memoria, capacidad de sntesis,
abstraccin, clculo, juicio). ______________________________________
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Autoconcepto _________________________________________________
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Atencin, concentracin _________________________________________
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Conciencia de enfermedad________________________________________
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Contratransferencia:_____________________________________________
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8. Exmenes
Psicolgicos:
Personalidad _______________________________________________
Inteligencia ________________________________________________
Proyectivos ________________________________________________
Neuropsicolgicos __________________________________________
Otros _____________________________________________________
9. Tratamientos previos
(prescripciones, respuesta a tratamientos, automedicacin) ________________
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L. 1. Diagnstico Multiaxial
Eje I (Trastornos mentales y del comportamiento DSM IV)
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Eje II
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Eje III (Enfermedades mdicas relacionadas)
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Eje IV (Problemas psicosociales y ambientales)
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Eje V (Evaluacin de la actividad global *Escala EEAG)
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L. 2. Diagnstico descriptivo.
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M. Pronstico _______________________________________________
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N. Plan teraputico
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O. Evolucin
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Nombre y firma
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Cdula Prof.
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