Académique Documents
Professionnel Documents
Culture Documents
I. Antecedentes Personales:
Fecha de Nac. Edad y Mes Sexo Cant. de Hermanos Lugar entre Hermanos
/ /
Domicilio
Motivo de Consulta
Fecha de Realizacin: / /
A. Pre Natal.
Observaciones:
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B. Peri Natal.
Parto:
Horas Transcurridas desde las Primeras Contracciones hasta el Parto
De trmino Prematuro Posmaturo Rpido Lento Normal
Espontneo Inducido Cesrea Frceps Plac. previa Seco
Atendida Oportunamente Lugar de Parto
Estuvo Anestesiada durante el Parto Gemelo Naci primero
Observaciones:
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C. Post Natal.
Observaciones:
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D. Situacin Actual.
Siempre
Siempre
A veces
A veces
Nunca
Nunca
PERSONALIDAD SE QUEJA O PRESENTA
Siempre
A veces
Nunca
barra CONDUCTAS DE AUTOVALIA
Tiene miedos especficos
Aptico
Respeta turnos
Obsesivo Cuida y ordena sus cosas
Olvidadizo Come solo
Impaciente Trabaja solo
Melanclico Obedece fcilmente
Porfiado Se viste solo
Interrumpe Duerme solo
Malos modales Resuelve sus problemas solo
Conducta frentica
Agresivo
Siempre
A veces
Vergonzoso
Nunca
Llorn HBITOS
Dependiente
Se desanima fcilmente Terror nocturno
Teme al castigo Insomnio
Nervioso Hipersomnia (duerme mucho)
Excesivamente meticuloso Sonambulismo
No quiere ir al colegio Sueo normal
Distrado Sueo intranquilo
Irresponsable Onicofagia (se come las uas)
Poco sociable Bruxismo (hace sonar los
Tmido dientes)
Acepta crticas Enuresis D N
Destructivo Encopresis D N
Observaciones:
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Grupo Familiar:
Normalmente constituido Unin libre
Padres separados Vive con otros familiares
Personas con quienes vive el nio
Ocupacin
Ocupacin
Hermanos/as:
Nombre Edad Sexo Estudios Ocupacin
Observaciones:
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Ha padecido:
Peste cristal Sarampin Rubola Varicela
Tos convulsiva Paperas Difteria Intoxicaciones
Patolgicos Familiares:
Familiar Gravedad Duracin
Epilepsia
Alcoholismo
Enfermedades neuro-
psquicas
Dificultad para hablar
Dificultad para aprender
a leer
Torpeza motora
Tuberculosis
Otros
Observaciones:
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V. Antecedentes Escolares:
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Observaciones:
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