ENTREVISTA INICIAL

I.-DATOS GENERALES
Nombre:_______________________ Edad:_________ Sexo:___________
Fecha de nacimiento:_______________________________________________
Lugar de nacimiento: _______________________________________________
Domicilio:_________________________________________________________
Ocupacin:______________Puesto:__________________Antiguedad:_________
Estado civil: _______________________________________________________
Escolaridad:______________Interno_______________Externo_______________
Creencia Religiosa______________

II.-OBJETIVO: Exploracin de signos y sntomas para llegar al diagnostico

III.-MOTIVO DE CONSULTA: Elaboracin de diagnostico

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IV.--FAMILIOGRAMA

V.-ANTECEDENTES Y TIEMPO DE PRESENTACION DE SIGNOS Y SNTOMAS

Fisicos:____________________________________________________________________
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Psicologicos:_______________________________________________________________
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Sociales:__________________________________________________________________
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Emocionales:_______________________________________________________________
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VI.-EVENTOS SIGNIFICATIVOS DEL MOTIVO DE CONSULTA
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VII.-DATOS SOCIODEMOGRAFICOS
Familia:___________________________________________________________________
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Trabajo:___________________________________________________________________
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Grupo de iguales:__________________________________________________________
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Intereses:_________________________________________________________________
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VIII.-POSIBLE DIAGNSTICO
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IX.-OBSERVACIONES
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NOMBRE Y FIRMA DEL PSICLOGO

ATLACOMULCO, MXICO A________DE____________ DE 20_______