I.

DATOS GENERALES

NOMBRE: ______________________________ APELLIDOS: ____________________________

FECHA DE NACIMIENTO: ________________________PROGENIA: _____ EDAD: _____ SEXO: _____

ESTADO CIVIL: C__ S__ UL__ V__ ESCOLARIDAD: ____________________________________

N° DE TEL: Casa ___________________ Celular _____________________

DIRECCIÓN:
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OCUPACIÓN: ___________________________________ RELIGIÓN: _____________________

FECHA: ________________________ N° EXPEDIENTE: __________

II. MOTIVO DE REMISIÓN:

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SINTOMA PRINCIPAL:
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III. OBSERVACIONES (Impresión personal)

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IV. ANTECEDENTES DEL PROBLEMA

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V. ANTECEDENTES FAMILIARES:
 DINÁMICA FAMILIAR

RELACIÓN CON EL ESPOSO (A):

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RELACIÓN HIJOS:
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TIPO DE HOGAR:

PADRES:
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HERMANOS:
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OTROS:
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ACTITUD DE LA FAMILIA ANTE EL PROPLEMA:

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SENTMIENTO DE EL O ELLA HACIA LA FAMILIA:

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VI. HISTORIA PERSONAL

PRIMERA INFANCIA:
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ADOLESCENCIA:
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HASTA LA ACTUALIDAD:
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HISTORIA LABORAL:

LABORA: SI ________ NO _______ LUGAR DE TRABAJO: ________________________

CARGO QUE DESEMPEÑA: ________________________________________________

CUANTO TIEMPO TIENE DE LABORAR EN ESE LUGAR Y CARGO:

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VII. SEXUALIDAD:

ACTITUD HACIA LA SEXUALIDAD: ________________________________________

RELACIONES CON EL O LA ESPOSA:

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DISFUNCIONES SEXUALES:
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VIII. SOCIALIZACIÓN

AMISTADES/ACTIVIDADES RECREATIVAS:
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PROBLEMAS EN LAS RELACIONES INTERPERSONALES:

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IX. PERSONALIDAD
PERSONALIDAD PREVIA A LA CRISIS:
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PERSONALIDAD POST- LIMITACIÓN (DEPRESIO, ANGUSTIA, ANSIEDAD, ETC.):

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ESTADO MENTAL GENERAL:

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X. HÁBITOS

ABUSO ALCOHOL/DROGAS/CIGARRILLOS:
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OTROS: _________________________________________________________________________

¿DESDE CUANDO Y POR QUÉ?

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XI. AUTOCONCEPTO Y EXPECTATIVAS:

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XII. CONCLUSION
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XIII. SUGERENCIAS Y RECOMENDACIONES
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