Universidad Mariano GlvezCentro Regional, CoatepequeWalter Alexander de Paz O.

FICHA CLNICA DE NIOSI. DATOS DE IDENTIFICACIN PERSONAL:

Nombre completo del paciente:_______________________________________________Edad: ______________Sexo: _______________ Fecha de nacimiento:________________Direccin:____________________________________Tels:________________________Nombre de la madre: ___________________Edad:_______________________________Nombre del padre: _____________________Edad:_______________________________Ocupacin del padre: ________________________Escolaridad:____________________Ocupacin de la madre: ______________________Escolaridad:____________________No. de hermanos: _________________ Lugar que ocupa:__________________________Es hijo de padres divorciados o separados?___________________________________Religin que profesa:_______________________________________________________Fecha de Consulta:_________________________________________________________Nombre del acompaante en la entrevista:_____________________________________Parentesco del acompaante:________________________________________________Motivo de consulta:________________________________________________________Por quin fue referido?____________________________________________________Recibi otras terapias?____________________________________________________Tiene tratamiento mdico?_________________________________________________

FECHA DE INICIO Y DURACIN DEL PROBLEMA: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________FACTORES PRECIPITANTES: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________IMPACTO DEL TRASTORNO EN EL SUJETO Y EN LA FAMILIA:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

II. HISTORIAL CLNICOQu enfermedades ha padecido desde su nacimiento?

Tiene las siguientes vacunas?Sarampin______________ D.P.T.__________________ Hepatitis B_______________Poliomielitis_____________ D.P.____________________ B.C.G.__________________ T.T.____________________

III. CONDICIN DEL EMBARAZO

Naci a los 9 meses?____________________ 7 meses?_______________________________El parto fue normal?_________ Por Cesrea?__________ Utilizaron frceps?____________Hubo alguna complicacin en el proceso del embarazo? Si____________ No __________Cul?________________________________________________________________________Ha tenido abortos, y cuntos?_____________________________________________________Tubo hemorragias durante el embarazo?_____________________________________________Padeci alguna infeccin o enfermedad durante el embarazo?__________________________________________________________________________________________________________________Ingiri algn medicamento durante el embarazo?______________________________________Cunto tiempo dur en labor de parto?______________________________________________El nio llor pronto:______________ Respir inmediatamente:___________________________Naci amarillo o morado?________________________________________________________Hubo sufrimiento fetal?__________________________________________________________Peso y medida a la hora de nacer:___________________________________________________Fue un embarazo deseado?_______________________________________________________

IV. HISTORIA FAMILIAR: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________GENOGRAMA:

V. ASPECTO SOCIAL

Es extrovertido?_______________________________________________________________Es introvertido?________________________________________________________________Es comunicativo?______________________________________________________________Se enoja fcilmente?____________________________________________________________Cmo es la relacin con sus hermanos?_____________________________________________Cmo es la relacin con sus compaeros de clase?_________________________________________________________________________________________________________________Con quines acostumbra a jugar?_______________________________________________________________________________________________________________________________Cules son sus juguetes preferidos?_____________________________________________________________________________________________________________________________Juega con animales?____________________________________________________________Padece enuresis?_______________________________________________________________Padece encopresis?_____________________________________________________________Es comunicativo?______________________________________________________________

VI. ASPECTO PSICOLGICOEs colrico?___________________________________________________________________Es nervioso?__________________________________________________________________Es aptico?___________________________________________________________________Pone atencin?________________________________________________________________Es obediente?_________________________________________________________________Es agresivo?__________________________________________________________________Tiene pesadillas nocturnas?______________________________________________________Es sonmbulo?________________________________________________________________Regularmente, se le ve sonrer?___________________________________________________Sufre de insomnio?_____________________________________________________________Llora de noche?_______________________________________________________________Es hiperactivo?________________________________________________________________Se succiona el dedo?____________________________________________________________Controla esfnteres?____________________________________________________________Se juega el pelo?_______________________________________________________________

VI. EVOLUCIN DEL LENGUAJEBalbuce?_____________________________________________________________________Vocaliz en los primeros meses?___________________________________________________Edad en que dijo la primera palabra y primera frase___________________________________________________________________________________________________________________Grado que cursa_________________________________________________________________Repiti algn grado?_____________________Por qu?____________________________________________________________________________________________________________Cmo es su adaptacin social?__________________________________________________________________________________________________________________________________

I. PLAN TERAPUTICO, TCNICAS, ESTRATEGIAS, MTODOS Y RECOMENDACIONES: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

II. NOTAS EVOLUTIVAS : _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Lugar y de la Entrevista: __________________________________________________

FIRMA:

______________________________________________________WALTER ALEXANDER DE PAZ OROZCO: SPTIMO SEMESTRE DE PSICOLOGA CLNICANMERO DE CARNET: 3772-12-1321

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