25. Formato Informe de Examen Mental

INFORME DE EXAMEN MENTAL I. DATOS GENERALES . Nombres y apellidos

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. Edad

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. Sexo

:

. Fecha de nacimiento

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. Lugar de nacimiento

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. Número de hermanos

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. Lugar entre hermanos

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. Domicilio

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. Teléfono

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. Grado de instrucción

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. Estado civil

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. Fecha de evaluación

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. Entrevistador

F

M

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II. DESCRIPCIÓN GENERAL a) Apariencia  __________________  ___________________________ ___________________ _________________ _________________ ___________________ ___________________ ____________ __  __________________  ___________________________ ___________________ _________________ _________________ ___________________ ___________________ ____________ __  __________________  ___________________________ ___________________ _________________ _________________ ___________________ ___________________ ____________ __ b) Comportamiento y actividad motora  __________________  ___________________________ ___________________ _________________ _________________ ___________________ ___________________ ____________ __  __________________  ___________________________ ___________________ _________________ _________________ ___________________ ___________________ ____________ __  __________________  ___________________________ ___________________ _________________ _________________ ___________________ ___________________ ____________ __  __________________  _____________________________ ____________________ __________________ ___________________ ___________________ __________________ _________ c) Actitud hacia el examinador  __________________  ___________________________ ___________________ _________________ _________________ ___________________ ___________________ ____________ __  __________________  ___________________________ ___________________ _________________ _________________ ___________________ ___________________ ____________ __  __________________  ___________________________ ____________________ ____________________ ___________________ ___________________ __________________ _________  __________________  ___________________________ ___________________ _________________ _________________ ___________________ ___________________ ____________ __

III. HUMOR Y AFECTO a) Humor  __________________  ___________________________ ___________________ _________________ _________________ ___________________ ___________________ ____________ __  __________________  ___________________________ ___________________ _____________________ ____________________ _________________ _________________ __________ _  __________________  ___________________________ ___________________ _________________ _________________ ___________________ ___________________ ____________ __

b) Afecto  ___________________________________________________________________________  ___________________________________________________________________________  ___________________________________________________________________________ c) Propiedad  ___________________________________________________________________________  ___________________________________________________________________________  ___________________________________________________________________________

IV. LENGUAJE  ___________________________________________________________________________  ___________________________________________________________________________  ___________________________________________________________________________  ___________________________________________________________________________ V. ALTERACIONES SENSOPERCEPTIVAS  ___________________________________________________________________________  ___________________________________________________________________________  ___________________________________________________________________________  ___________________________________________________________________________ VI. PENSAMIENTO  ___________________________________________________________________________  ___________________________________________________________________________  ___________________________________________________________________________  ___________________________________________________________________________ VII.

SENSORIO Y COGNICIÓN

a) Alerta y nivel de conciencia  ___________________________________________________________________________  ___________________________________________________________________________ b) Orientación  ___________________________________________________________________________  ___________________________________________________________________________ c) Memoria  ___________________________________________________________________________  ___________________________________________________________________________ d) Concentración y atención  ___________________________________________________________________________  ___________________________________________________________________________ e) Capacidad de lectura y escritura  ___________________________________________________________________________  ___________________________________________________________________________ f) Habilidad viso espacial  ___________________________________________________________________________  ___________________________________________________________________________ g) Pensamiento abstracto  ___________________________________________________________________________  ___________________________________________________________________________ h) Consolidación de información de inteligencia

 ___________________________________________________________________________  ___________________________________________________________________________

VIII.

CONTROL DE IMPULSOS  ___________________________________________________________________________  ___________________________________________________________________________  ___________________________________________________________________________  ___________________________________________________________________________ IX. JUICIO E INSIGHT  ___________________________________________________________________________  ___________________________________________________________________________  ___________________________________________________________________________  ___________________________________________________________________________ X. FIABILIDAD  ___________________________________________________________________________  ___________________________________________________________________________  ___________________________________________________________________________  ___________________________________________________________________________

Anexos. Examen mental del evaluado.