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# de Historia:

Fecha:

ENTREVISTA INFANTIL

I. Datos de Identificacin del Paciente

Nombres y Apellidos: _________________________________________________


Lugar y Fecha de nacimiento: __________________________________________
Edad: ____________ Sexo: ________________ C.I: __________________
Escuela: ____________________________________________________________
Grado: ______________ Turno: _________________ Repite: ________________
Docente: ___________________

II. Datos de Identificacin del Familiar o Representante

Madre:

Nombre y Apellido: __________________________________________________


Lugar y Fecha de Nacimiento: __________________________________________
Edad: _____________ C.I: _____________________________________________
N de hijos: ____________________ Estado Civil: __________________________
Grado de instruccin: ________________________________________________
Profesin: _________________________ Trabajo: _________________________
Direccin: __________________________________________________________

Padre:

Nombre y Apellido: __________________________________________________


Lugar y Fecha de Nacimiento: __________________________________________
Edad: _____________ C.I: _____________________________________________
N de hijos: ____________________ Estado Civil: __________________________
Grado de instruccin: ________________________________________________
Profesin: _________________________ Trabajo: _________________________
Direccin: __________________________________________________________

Representante:

Nombre y Apellido: __________________________________________________


Lugar y Fecha de Nacimiento: __________________________________________
Edad: _____________ C.I: _____________________________________________
N de hijos: ____________________ Estado Civil: __________________________
Grado de instruccin: ________________________________________________
Profesin: _________________________ Trabajo: _________________________
Direccin: __________________________________________________________
III. Motivo de Consulta

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IV. Antecedentes Pre Para y Post Natales:

Embarazo:

ESTADO PSICOLGICO: ____________________________________________________________________


HIJO DESEADO: __________SEXO DESEADO: _______ EMB. NORMAL: ___________________________
CONTROLADO: _____________ N DE SEMANAS: ______________________________________________
COMPLICACIONES EN EL EMBARAZO: _______________________HIPERTENSIN: _______________
EDEMA: __________ AMENAZA DE ABORTO: ___________ ABORTOS: ___________________________
CAUSAS: ________________________TRAUMATISMOS: ______ CONFLICTO RH: ___________________
RADIOTERAPIAS: _____________________ OTROS: ____________________________________________
TRATAMIENTOS MEDICOS RECIBIDOS: _____________________________________________________
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Parto:
NORMAL: ____________ A TERMINO: __________ INDUCIDO: ___________ PREMATURO: __________
CESAREA: ________ POR QUE?: _____________________________________________________________
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Complicaciones:
RUPTURA PRECOZ DE MEMBRANA: ___________________ TRAUMATISMOS: __________________
CIRCULAR DE CORDN: ___________________________FRCEPS: _______________________________

Condiciones del recin nacido:


PRESENTACIONES AL NACER: CEFLICO: _______ PODLICO: _______ CIANTICO: ____________
ICTERICO: ___________ CONVULSIONES: ___________ DIFIC. DE SUCCIN: ______________________
DIFIC. PARA LLORAR: __________________ REANIMACIN: ____________________________________
INCUBADORA: _____________________OXIGENO:_____OTROS:_____________________________
PESO Y TALLA AL NACER:__________________________________________________________________
TRATAMIENTO MEDICO: __________________________________________________________________

Desarrollo Evolutivo:
ALIMENTACIN PRIMER AO DE VIDA:____________________________________________________
EDAD DEL DESTETE:_____________________ LEVANTO LA CABEZA:______________________
CAMIN:___________ SE SENT:___________GATE:____________ SE PAR:_____________________

Desarrollo del Lenguaje:


VOCALIZACIONES: ________SILABACIONES: _________________________BALBUCEO: ____________
PRIMERAS PALABRAS CON SIGNIFICADO: ______________________FRASES: _______________
ORACIONES: ______________ PRESENTA ALGUNA DIFIC. DE LENGUAJE: ________________________
DE QUE TIPO: ______________________________ OYE BIEN: ____________________________________
COMPRENDE TODO LO QUE SE LE DICE: _________________ OTROS: ____________________________
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V. Condiciones Generales de Salud

CONDICIONES DE SALUD DURANTE EL PRIMER AO DE VIDA: ________________________________


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Enfermedades Significativas:
SARAMPIN:_____ RUBOLA:_______ TOS FERINA:______ PAPERAS:______ LECHINA:______
MENINGITIS:_________ ENCEFALITIS:________ CONVULSIONES:_______ EPILEPSIA:________
OTITIS CRNICA:______________ T.C.E. TRAUMATISMO CRANEOENCEFLICO:____________
CARDIOPATIAS:________ DOLORES DE CABEZA PERIODICOS:________ DESMAYOS:_____________

INTERVENCIONES QUIRRGICAS: ________________________________________________________


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TRATAMIENTOS MDICOS QUIRRGICOS: ________________________________________________


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Exmenes:
E.E.G.(FECHA Y RESULTADOS): _____________________________________________________________
RADIOGRAFIAS:___________________________________________________________________________
OTROS: ___________________________________________________________________________________

ACCIDENTES: ____________________________________________________________________________
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CONTROL PEDITRICO

SI________ NO________

CONDICIONES ACTUALES DE SALUD: _____________________________________________________


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VI. Hbitos

SUEO:

N DE HORAS QUE DUERME: ______________ SE ACUESTA VOLUNTARIAMENTE:___________


DUERME SOLO:______ ACOMPAADO:________

ALIMENTACIN:__________________________________________________________________________
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ASEO PERSONAL: ________________________________________________________________________
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VII. Control de Esfnter:

VESICAL: ________________________________________ANAL: __________________________________


MTODO EDUCATIVO: ____________________________________________________________________
PROBLEMAS SURGIDOS: ___________________________________________________________________

VIII. Sntomas Neurticos

ENURESIS DIURNA:______________ NOCTURNA:_____________ OCASIONAL: _____________


ENCOPRESIS DIURNA:____________ NOCTURNA:____________ OCASIONAL: _____________
ONICOFAGIA SI__________ NO__________SUEO NORMAL______
INTRANQUILO______ TERROR NOCTURNO_______ INSOMNIO______ DUERME DEMASIADO______
SONAMBULISMO______ BRUXISMO_______ PESADILLAS_____________________________________
CHUPARSE EL DEDO______MORDERSE LOS LABIOS______ SUCCIONARSE LA LENGUA__________
SE HALA LAS OREJAS, EL PELO, LA NARIZ_________ SE FROTA LOS OJOS_______________________
MOVIMIENTOS ROTRICOS DE LA CABEZA________ TICS NERVIOSOS_________________________
GOLPEA LA CABEZA CON LAS MANOS__________ CURIOSIDAD SEXUAL_______________________

IX. Escolaridad

INGRESO AL PREESCOLAR: _________________________ADAPTACIN: _________________________


EDUCACIN BSICA: ______________________________________________________________________
RENDIMIENTO GENERAL:__________________________________________________________________
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DIFICULTADES PRESENTADAS: ____________________________________________________________
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REPITENCIAS: _______________________CUAL (ES) GRADO (S):_________________________________
RAZONES DE REPITENCIA:_________________________________________________________________
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CONDUCTA EN LA ESCUELA: ______________________________________________________________
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CON LOS COMPAEROS: __________________________________________________________________
CON LA MAESTRA: ________________________________________________________________________
ACTITUD HACIA LOS ESTUDIOS: ___________________________________________________________
HORARIO ESTABLECIDO PARA REALIZAR SUS ACTIVIDADES ESCOLARES: ____________________
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REALIZA SUS TAREAS SOLO O CON AYUDA: _________________________________________________
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REALIZA SUS ACTIVIDADES ESCOLARES EN LUGAR ADECUADO:_____________________________
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SE DISTRAE CON FACILIDAD: Si ___________ No _______________
EXPLIQUE: _______________________________________________________________________________
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CUENTA CON MATERIAL DE APOYO NECESARIO PARA REALIZAR SUS ACTIVIDADES
ESCOLARES:______________________________________________________________________________
ASISTE CON REGURALIDAD A LA ESCUELA:_________________________________________________
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N DE PLANTELES EDUCATIVOS Y NOMBRE DONDE HA REALIZADO SU ESCOLARIDAD
PBLICOS:________________________________________________________________________________
PRIVADOS:_______________________________________________________________________________
X. rea Socio-Emocional

PERSONALIDAD DEL NIO/A:


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RELACIONES INTERPERSONALES DE(L) (LA) NI@ DENTRO DEL GRUPO FAMILIAR CON PAREJA
PARENTAL: ______________________________________________________________________________
HERMANOS: ______________________________________________________________________________
OTROS FAMILIARES: ______________________________________________________________________

RELACIONES INTERPERSONALES DE(L) (LA) NI@ FUERA DEL GRUPO FAMILIAR (COMPAEROS
Y OTROS) _________________________________________________________________________________
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ACTIVIDADES QUE REALIZA EL (LA) NI@ (JUEGOS, DIVERSIONES, DEPORTES Y OTROS)


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XI. Dinmica Familiar (interna y social)

RELACIONES INTRAFAMILIA (CONYUGALES, VNCULOS CON LOS HIJOS Y OTROS HERMANOS,


AMBIENTE FAMILIAR ACTUAL): ____________________________________________________________
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XII. Genograma

XIII. Antecedentes Patolgicos Familiares

LNEA MATERNA: _________________________________________________________________________


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LNEA PATERNA: _________________________________________________________________________


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XIV. Condiciones Fsico Ambientales
TIPO DE VIVIENDA: _______________________________________________________________________
TENENCIA DE LA VIVIENDA: _______________________________________________________________
DISTRIBUCIN DE LA VIVIENDA: ___________________________________________________________
QUIENES TRABAJAN:______________________________________________________________________
QUIENES APORTAN:_______________________________________________________________________
N DE FAMILIARES QUE HABITAN: __________________________________________________________

XV. Condiciones Socio Econmicos

DISTRIBUCIN DE GASTOS O EGRESOS:


INGRESO MENSUAL_______________________________________________________________________
INGRESO MENSUAL FAMILIAR_____________________________________________________________

GASTOS QUE USTED REALIZA:


ALIMENTACIN: _________________________________________________________________________
VIVIENDA: ______________________________________________________________________________
ALQUILER: ______________________________________________________________________________
SERVICIOS PBLICOS: ____________________________________________________________________
AGUA:_______________ GAS:______________ TELFONO:______________________________________
ELECTRICIDAD___________ EDUCACIN: ___________________________________________________
ACTIVIDAD RECREATIVA: _________________________________________________________________
OTROS:___________________________________________________________________________________
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XVI. Impresin Del Entrevistado

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XVII. Observaciones

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