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

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. Edad

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. Sexo

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. 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

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F

M

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.