COLOMBIANA DE SALUD S.A.

MANUAL DE CALIDAD

FORMATO HISTORIA CLINICA Page 1 of 1 CDS-PSO 2.7.3.1 F1

PSICOLOGICA ADULTOS
Revisión 00 Mayo 2009

HISTORIA CLÍNICA PSICOLOGICA ADULTOS

DATOS DE IDENTIFICACIÓN

NOMBRE:________________________________________ IDENTIFICACION:__________________
EDAD:__________ESTADO CIVIL:___________________PROCEDENCIA:_____________________
DIRECCIÓN:____________________________________TELÉFONO:__________________________
OCUPACIÓN:_________________________FECHA DE ELABORACIÓN:______________________

MOTIVO DE CONSULTA:_____________________________________________________________
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ANTECEDENTES:____________________________________________________________________
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HISTORIA PERSONAL: ______________________________________________________________

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HISTORIA FAMILIAR:_______________________________________________________________
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 COLOMBIANA DE SALUD S.A. MANUAL DE CALIDAD

FORMATO HISTORIA CLINICA Page 2 of 2 CDS-PSO 2.7.3.1 F1

PSICOLOGICA ADULTOS
Revisión 00 Mayo 2009

ESPERAS DEL FUNCIONAMIENTO

LABORAL:__________________________________________________________________________
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SOCIAL:____________________________________________________________________________
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AFECTIVA:_________________________________________________________________________
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OTRAS:_____________________________________________________________________________
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VALORACIÓN GENERAL:____________________________________________________________
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IMPRESIÓN DIAGNOSTICA:__________________________________________________________
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PLAN DE TRATAMIENTO:___________________________________________________________
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FIRMA Y SELLO PROFESIONAL TRATANTE