E N T R E V I S T A P A C I E N T E

FECHA: _______________________________________

Datos:
NOMBRE: __________________________________________________________
EDAD: ______________________SEXO: _________________________________
ESCOLARIDAD: _____________________FECHA DE NAC.: __________________

Cmo te llamas?
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Cuntos aos tienes?
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Dnde vives?
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Cmo se llama tu mam?
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Cmo se llama tu pap?
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Vives con ellos?
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Quin es la persona que te cuida?
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Tienes hermanos? ___________________________
Cuntos? ___________________________________
Cmo se llaman tus hermanos?
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Cmo se llama tu maestra?
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A qu te gusta jugar?
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Qu programa de televisin te gusta ms?
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Qu haces en tu tiempo libre?
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Te gusta ir a la escuela?
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Cul es la materia que ms te gusta?
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Cul es la materia que menos te gusta?
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Cuntos amigos tienes en la escuela?
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Cmo se llaman?
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Qu te gustara ser cuando seas grande? Y Por qu?
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Qu lugar te gustara conocer? Y Por qu?
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A T E N T A M E N T E

KARINA GARCA JUREZ

LIC. EDUCACIN ESPECIAL Y PSICOPEDAGOGA