Anamnesis

1. DATOS PERSONALES

Nombre
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Edad
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Fecha de nacimiento : ___________________________________________________________
Lugar de nacimiento : ___________________________________________________________
Sexo
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Centro de estudios : ___________________________________________________________
Grado de Instruccin : ___________________________________________________________
Direccin
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Telfono
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Fecha de consulta
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2. PROBLEMA
ACTUAL___________________________________________________________________
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OBSERVACIONES:___________________________________________________________________
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3. HISTORIA FAMILIAR
PADRE
Datos Generales
Nombre
: ________________________________________________
Edad
: ________________________________________________
Grado de Instruccin : ________________________________________________
Centro de Labores : ________________________________________________
Telfono
: ________________________________________________
Carcter
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Anamnesis

Enfermedades
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MADRE
Datos Generales
Nombre
: ________________________________________________
Edad
: ________________________________________________
Grado de Instruccin : ________________________________________________
Centro de Labores : ________________________________________________
Telfono
: ________________________________________________
Carcter
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Enfermedades
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HERMANOS
Datos Generales
Nombre
:
Edad
:
Grado de Instruccin :
Centro de Labores :
Telfono
:

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Carcter
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Enfermedades
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HERMANOS
Datos Generales
Nombre
: ________________________________________________
Edad
: ________________________________________________
Grado de Instruccin : ________________________________________________

Anamnesis

Centro de Labores
Telfono

: ________________________________________________
: ________________________________________________

Carcter
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Enfermedades
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HERMANOS
Datos Generales
Nombre
: ________________________________________________
Edad
: ________________________________________________
Grado de Instruccin : ________________________________________________
Centro de Labores : ________________________________________________
Telfono
: ________________________________________________
Carcter
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Enfermedades
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HERMANOS
Datos Generales
Nombre
:
Edad
:
Grado de Instruccin :
Centro de Labores :
Telfono
:

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Carcter
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Enfermedades
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HERMANOS
Datos Generales
Nombre
:
Edad
:
Grado de Instruccin :
Centro de Labores :
Telfono
:
:

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Anamnesis

Carcter
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Enfermedades
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ABUELOS PATERNOS
Datos Generales
Nombre
:
Edad
:
Grado de Instruccin :
Centro de Labores :
Telfono
:

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Carcter
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Enfermedades
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ABUELOS PATERNOS
Datos Generales
Nombre
:
Edad
:
Grado de Instruccin :
Centro de Labores :
Telfono
:

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Carcter
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Enfermedades
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ABUELOS MATERNOS
Datos Generales
Nombre
:
Edad
:
Grado de Instruccin :
Centro de Labores :
Telfono
:

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:
Carcter
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Anamnesis

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Enfermedades
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ABUELOS MATERNOS
Datos Generales
Nombre
:
Edad
:
Grado de Instruccin :
Centro de Labores :
Telfono
:

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Carcter
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Enfermedades
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NIERA O SUSTITUTO
Datos Generales
Nombre
:
Edad
:
Grado de Instruccin :
Centro de Labores :
Telfono
:

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:
Carcter
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Enfermedades
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ACTITUDES DEL NIO RESPECTO LA FAMILIA

Comportamiento del nio con los padres
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Anamnesis

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Comportamiento del nio con los hermanos
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Adaptacin al hogar
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Area de inadaptacin
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ACTITUDES DE LOS PADRES HACIA EL NIO

Actitud del Padre
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Actitud de la madre
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Modo de sancin
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Actitud frente a la crianza
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Anamnesis

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Expectativas frente al nio
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4. AMBIENTE FAMILIAR
Carcter del ambiente
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Problemas
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5. HISTORIAL PERSONAL
Embarazo
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Nacimiento
Parto
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Actitudes
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Anamnesis

Alimentacin
Actitudes
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Problemas
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Sueo
Hbitos
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Alteraciones
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Desarrollo Motor
Evolucin
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Problemas de lenguaje
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Desarrollo Emocional
Afectividad
Personal
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Animales
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Relaciones emocionales
Frustracin
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Estrs
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Anamnesis

Castigo
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Hostilidad de otros
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Temores y estados ansiedad

Grado de independencia
Animo prevalente
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Grado adaptacin
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Sntomas neurticos
Enuresis
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Onicofagia
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Otros
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Desarrollo Social
Relaciones con los adultos
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Relaciones con nios
Mayores
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Menores
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Anamnesis

De su edad
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Grado de colaboracin
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Grado de generosidad
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Adaptacin general
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Perturbaciones
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6. ETAPA ESCOLAR
Pre Escolar
Adaptacin
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Primaria
Rendimiento
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Adaptacin
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Area del problema
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Secundaria
Rendimiento
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Anamnesis

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Adaptacin
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Area del problema
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Desarrollo Social en la escuela
Relacin con los profesores
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Relacin con los compaeros
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Disciplina
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Responsabilidad
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Otros estudios
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7. HABITOS E INTERESES
Escolares
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Extra escolares
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Anamnesis

Ldicos
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Sociales
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Religiosos
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8. DESARROLLO SEXUAL
Primeros intereses
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Masturbacin
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Enamoramientos
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Relaciones Sexuales
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9. ENFERMEDADES Y ACCIDENTES
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Anamnesis

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10.CAMBIOS DE RESIDENCIA
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INFORMANTE
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Anamnesis