N° H.C.: ____________
FECHA: ___/_____/_____
FICHA DE ATENCIÓN INICIAL
I. DATOS PERSONALES
1. Nombres y apellidos: ……………………………………..……………………………………
2. Edad: ……………………....
DNI: ……………………….
3. Fecha y Lugar de Nacimiento: ……………………………………………………………….
4. Sexo: ………………………
5. Grado académico y/o ocupación: …………………………………………………….
6. Domicilio: …………………………………………………………………………………...
7. Estado Civil: …………………………………………………………………………………...
8. Nro de hijos: ………………………………………………………………………………
9. Lic. Responsable: …………………………………………………………………………….
II. DIAGNÓSTICO: ___________________________________________________________
III. DATOS FAMILIARES:
PARENTESCO
NOMBRES Y APELLIDOS
EDAD
OCUPACIÓN
¿VIVE EN
CASA?
IV. MOTIVO DE CONSULTA:
_____________________________________________________________________________
_____________________________________________________________________________
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N° H.C.: ____________
V. ANTECEDENTES RELEVANTES:
____________________________________________________________________________
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VI. OBSERVACIÓN GENERAL:
____________________________________________________________________________
_____________________________________________________________________________
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_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
VII. PROBLEMA ACTUAL:
_____________________________________________________________________________
_____________________________________________________________________________
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_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
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VIII. PLAN TERAPEUTICO:
_____________________________________________________________________________
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IX. IMPRESIÓN DIAGNÓSTICA (DSM V / CIE):
_____________________________________________________________________________
_____________________________________________________________________________
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