Isabel Kranwinkel

2009-1362

Entrevista Inicial
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DATOS GENERALES
NOMBRE: ________________________________________________________________
EDAD: ____________________________ SEXO: ________________________________
OCUPACIN: ______________________ ESCOLARIDAD: _______________________
DOMICILIO: ______________________________________________________________
REMITIDO POR: __________________________________________________________
MOTIVO:_____________________________________________________________________
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TELEFONO: __________________________

1. Historial Clnico
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2. Aspecto, actitud y conducta

Conducta

Sintnico

Distnico

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Aspecto

Cuidado

Descuidado

Extravagante

Bien arreglado

ESTILO DE VESTIR
BIEN REGULAR

MAL

DEPORTIVO
FORMAL
CASUAL
ALIO

Actitud

COMPORTAMIENTO
Confiado

Desconfiado

Extrovertido

Introvertido

Tranquilo

Inquieto

Cooperador

Renuente

Interesado

Aptico

Amable

Descorts

Relajado

Tenso

Conducta

Desinhibida

Desorganizada

Organizada

Observaciones
importantes:__________________________________________________________
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3. Conciencia
Hipervigilancia Obnubilacin
Somnolencia
Estupor
Coma
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4. Orientacin
Espacio, tiempo y persona.
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5. Memoria y atencin
Memoria inmediata, reciente y remota:
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6. Funcionamiento del lenguaje

LENGUAJE
Precipita en sus
respuestas

Contacto visual

Silencios

Expresin facial
concuerda con
mensaje verbal

Palabras rebuscadas

Aumento de voz

Calo

Voz baja

Gesticulacin

Conversador

Bostezo

7. Humor y afectividad
Humor
Eutmico Disfrico Irritabl
e

Variabilidad Anehedonia

Afectividad
Constriccin

Embotamiento

Aplanamiento

Labilidad emocional

8. Pensamiento
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Forma del pensamiento (fluido, disgregado, bloqueos, concreto)

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Contenido del pensamiento
Ideas extraas ASPECTO CORPORAL
Delirios
Alucinacin
Talla baja
Falsa identificacin
COMPLEXIN
Fuga de ideas
Exceso de peso
Robo de pensamiento
EDAD
Obsesiones
Menor
APARENTE
Fobias
Ideacin suicida

Talla alta
Delgadez
Mayor

9. Hbitos fisiolgicos

Sueo

Insomnio

Hipersomnia

Alteraciones

10. Evaluacin multiaxial

Eje I
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Eje II

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Eje III

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Eje IV

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Eje V

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11. Observaciones Finales
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Lic. Isabel Kranwinkel
Psicloga Clnica