ANAMNESIS

I. DATOS PERSONALES

Nombre: _________________________________________________

Edad: ___________________________________________________

Fecha de nacimiento: _______________________________________

Sexo: ____________________________________________________

Escolaridad: _______________________________________________

Lateralidad: ________________________________________________

Ocupacin: ________________________________________________

Domicilio: _________________________________________________

Telfono: ___________________________________________________

II. ANTECEDENTES MRBIDOS

a) Alteraciones sensoriales:
Hipoacusia __________ (Hipermetropa/Miopa/Astigmatismo_________
Compensada?_______
Justifique_______________________________________________________
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b) Traumatismo Encfalocraneano S ___ No ___ Cundo? ____

Justifique_______________________________________________________
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c) Trastorno Psiquitrico S___ No___

Justifique_______________________________________________________
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d) Accidente Cerebrovascular S___ No___ Cundo?___
Justifique_______________________________________________________
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e) Queja subjetiva de cognicin S___ No___
Justifique_______________________________________________________
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f) Consumo de drogas/alcoholismo S___ No___

Justifique_______________________________________________________
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g) Hipertensin Controlada?______
h) Diabetes Controlada?______
i) Colesterol Controlado?______
j) Alteraciones tiroideas
Hipotiroidismo_____ Hipertiroidismo_______ En tratamiento?______

k) Farmacodependencia
Medicamentos actuales______________ Frecuencia__________
l) Hipertrigliceridemia Controlada?_____

III. Antecedentes de reserva cognitiva (Rami, et al. 2011)

Escolaridad?
Justifique_______________________________________________________
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Escolaridad de los padres?

Justifique_______________________________________________________
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Cursos de formacin?
Justifique_______________________________________________________
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Ocupacin laboral?
Justifique_______________________________________________________
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Formacin musical?
Justifique_______________________________________________________
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 Idiomas?
Justifique_______________________________________________________
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Actividad lectora?
Justifique_______________________________________________________
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Juegos intelectuales (ajedrez, puzle, crucigrama)?

Justifique_______________________________________________________
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OBSERVACIONES:__________________________________________________
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