DATOS GENERALES

NOMBRE:__________________________________________ EDAD:__________________

FECHA Y LUGAR DE NACIMIENTO:______________________________________________

ULTIMO GRADO DE ESTUDIOS:_____________________ OCUPACION:_________________

ESTADO CIVIL:_______________________ RELIGION:_____________________________

DIRECCION:____________________________________________________________________
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TIEMPO DE RESIDENCIA:__________________ TELEFONO:__________________________

TELEFONO MOVIL:___________________ EMAIL:________________________________

ENTREVISTA

MOTIVO DE CONSULTA:

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INICIO Y SINTOMAS DEL MALESTAR:

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TIEMPO DE LA PROBLEMÁTICA:

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QUE SUCEDIÓ ESE DIA:

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EL DIA ANTERIOR:

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QUE HIZO:

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COMO SE CALMO:

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HABLO CON ALGUIEN DE LA PROBLEMATICA

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FACTORES DESENCADENANTES DEL PROBLEMA

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DESCRIPCION PERSONAL

COMO DESCRIBIRIRAS TU PERSONALIDAD

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CUAL ES TU FILOSOFIA DE VIDA

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HISTORIA PERSONAL

EDAD DE LA MADRE AL NACER:__________________ PARTO:________________________

TIPO DE ATENCION:_____________________ PORQUE:____________________________

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ESTATURA AL NACER:_______________________ PESO:___________________________

DESARROLLO PSICOMOTOR

LENGUAJE:___________________________ JUEGO:______________________________

EDAD A LA QUE CAMINO:__________________ CONTROL DE ESFINTERES:_________________

ALIMENTACION EN LA INFANCIA:_______________________________________________

CRIANZA POR AMBOS PADRES:________________________________________________

OTROS PARIENTES:_________________________________________________________

JUEGO INFANTIL

CON OTROS NIÑOS:____________________ AMIGOS IMAGINARIOS:___________________

OBSERVACIONES:_______________________________________________________________
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RELACION SOCIAL

CON LOS PADRES:

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CON LOS HERMANOS:

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OTROS FAMILIARES:

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CONOCIDOS:

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EXTRAÑOS DE LA MISMA EDAD:

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GRADO DE INTEGRACION:

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EXPERIENCIA EN EL ULTIMO GRADO DE ESTUDIOS:

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HABITOS E INTERESES (CONSUMO DE ALCOHOL, DROGAS, ETC.)

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ENFERMEDADES Y ACCIDENTES:
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ELECCION DE PROFESION:____________________________________________________

CONDUCTA SEXUAL (INICIO Y VIDA SEXUAL):

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ELECCION DE PAREJA

TE CUESTA TRABAJO ELEGIR PAREJA:____________________________________________

FIEL Y EXIGENTE:___________________________________________________________

NOVIAZGO (NUMERO Y DURACION DE ELLOS):_____________________________________

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OPINION DEL MATRIMONIO:__________________________________________________

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SINTESIS DE CITA:__________________________________________________________

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