HISTORIA CLNICA INFANTIL

FECHA ____/_____________________/ 20____/

ALUMNO(A)
DOCENTE

I.

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IDENTIFICACIN
NOMBRE

EDAD
SEXO

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ESTAB. EDUCACIONAL

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CURSO
PROFESOR(a) JEFE
TELFONO COLEGIO

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Femenino

Masculino

II. MOTIVO DE ENTREVISTA

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III. ANTECEDENTES GENERALES

EMBARAZO

Dificultad emocional de la

Comentarios
SI

NO

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madre
N de embarazos

Prdida(s)

Planificado

Deseado

Problemas de salud de la madre

OBSERVACIONES

PARTO

Normal

Problemas de recin nacido

Problemas emocionales de la
madre
PRIMEROS MESES

Lactancia

Tipo de adaptacin

Patrn de apego

PRIMEROS AOS
Antecedentes de alteraciones en:

Alimentacin

Sueo

Eliminacin
Desarrollo psicomotor:

Adquisicin de marcha

Adquisicin de lenguaje

Desarrollo psicomotor

Antecedentes de trastorno de
Conducta en los primeros aos

Antecedentes de enfermedades
Importantes

Golpes o cadas

Operaciones u hospitalizaciones:

- Por ciruga
- Por Enfermedades
Convulsiones

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SI
NO
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SI
NO
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SI
NO
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SI
NO
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SI
SI
SI

NO
NO
NO

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FCIL _____
LENTA _____
DIFCIL _____
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SI

NO

Comentarios
SI
SI
SI

NO
NO
NO

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SI
SI
SI

NO
NO
NO

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SI

NO

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SI

NO

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SI

NO

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SI

NO

SI
SI

NO
NO

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IV.

V.

GENOGRAMA

ANTECEDENTES FAMILIARES:
6.1 Madre (Nombre, edad, ocupacin, relacin con el nio, etc.):
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6.2 Padre (Nombre, edad, ocupacin, relacin con el nio, etc.):
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6.3 Hermanos (Nombres, describirlos de acuerdo a la edad, a la escolaridad, etc.):
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6.4 Persona con que el nio tiene mejor relacin
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6.5 Tipo de Afiliacin de los padres (matrimonio, separados, etc.):

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6.6 Persona con quien vive el nio en la casa:
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6.7 Otros antecedentes:
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VI.- ANTECEDENTES ACADMICOS:

Comentarios

Repitencia

SI

NO

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Dificultades de aprendizaje

SI

NO

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Dificultades con el profesor

SI

NO

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Dificultades de adaptacin escolar

SI

NO

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Dificultades para relacionarse con pares SI

NO

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Otros

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VII.- ANTECEDENTES SOCIALES

Comentarios

Problemas de integracin a pares

SI

NO

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Actitud pasiva

SI

NO

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Actitud agresiva

SI

NO

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Otros ___________________________________________________________________________

VIII.- CONSULTAS O TRATAMIENTOS PREVIOS

Comentarios

Psicologa

SI

NO

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Psicopedagoga

SI

NO

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Neurologas

SI

NO

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Psiquiatra

SI

NO

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Fonoaudiologa

SI

NO

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Otros ___________________________________________________________________________

X.- CARACTERSTICAS ESPECIALES

Comentarios

Talla baja o excesiva alta

SI

NO

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Pesos superior o inferior a normal

SI

NO

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SI

NO

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SI

NO

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Cicatrices visibles

SI

NO

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Tics

SI

NO

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Malformaciones congnitas

SI

NO

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Facia especial
(ej. Asimetra rasgos peculiares,
mirada, respiracin, facia
mongoloide, etc.
Rasgos exagerados
(tamao nariz, orejas, boca. )
Dentadura, manos de formas
Especiales, dedos

Otros
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IX. IMPRESIN CLNICA PRELIMINAR

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XII. OBSERVACIONES:
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NOMBRE Y FIRMA ALUMNOS