ANAMNESIS

I. DATOS GENERALES

Apellidos y nombres ____________________________________________________________

Fecha y lugar de nacimiento: _____________________________________________________

Edad (años y meses) ____________________________________________________________

Grado de instrucción ____________________________________________________________

Informantes (s) ________________________________________________________________

Nombres y edad Grado de Religión Ocupación

apellidos instrucción
Padre

Madre

Hermanos

Padrastro u
otros

II. MOTIVO DE CONSULTA

1. ¿Cómo se presentó esta dificultad? ¿desde cuándo? ¿Quién lo

detecto?_______________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
2. ¿Cuándo, dónde y con quien se presentó el problema?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

º1
 _______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
3. ¿Cómo ha evolucionado desde que apareció por primera vez? ¿ha notado alguna
mejoría?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
4. ¿Qué es lo que se ha intentado para solucionar este problema? Diagnostico (si lo
tuviera)
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
5. Según usted ¿Cuáles la causa del problema? ¿Cuál es la actitud frente al problema?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
6. Tratamiento recibidos ¿Cuánto tiempo? ¿en qué instituciones? Evaluación del
tratamiento_____________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

º2
Enfermedad actual

 Tipo de síndrome: (…….) años (…..) meses (…..) días

 Forma de inicio: (…….) brusco (…..) insidioso (…..) nacimiento
 Signos y síntomas principales:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Estresores importantes (que guardan relación con el problema del paciente, con las
causas que desencadenan conductas inapropiadas o que agraven el problema)
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Tratamientos farmacológicos (utiliza medicamentos necesarios u obligatorios,
especificar cuales, la dosis, horarios y método administración del o los medicamentos
que utiliza)
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

III HISTORIA EVOLUTIVA

1.- PRE – NATAL

 ¿Cuál es el número de embarazo con su hijo? ________________________________

 ¿Cómo fue su embarazo o gestación (condiciones) síntomas, problemas
duración_______________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

º3
 _______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 ¿fue planificado o deseado?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Tipo de control? Medico ____________ partera ____________ empírico ___________
 Enfermedades durante el embarazo, dificultades y/o accidentes, ingesta de
medicamentos, rayos x
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Ingesta de alcohol, tabaco, drogas y/o
anticonceptivos__________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 ¿perdidas? Causas
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

º4
2.- PERI - NATAL

 ¿a qué tiempo nación? __________ ¿Quién atendió el parto?

 Parto normal _________ cesárea ___________ con desgarramiento _______ o
inducido_________ ¿Por qué?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 ¿se utilizó anestesia? SI / NO ¿local? ______ general ______ ¿uso de instrumentos:
fórceps ____ vacum ______, etc. ______ ¿Por qué?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Presentación del recién nacido (peso, altura)
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Llanto al nacer _____ coloración ______ ¿necesito reanimación con oxígeno _____ o
incubadora ______ ¿Por cuánto tiempo?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

º5
  Edades de los padres, al momento de nacer el / la niña / (o) papa _____ mama _____

3.- POST – NATAL

 Malformaciones SI / NO ¿Cuáles?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Lactancia materna SI / NO. Dificultades en la succión SI /
NO____________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Dificultades después del parto SI / NO
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

IV. HISTORIA MÉDICA

 Estado de salud actual

_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Principales enfermedades. Medicamentos consumidos
_______________________________________________________________________

º6
 _______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Accidentes, golpes en la cabeza con pérdida de conocimiento ___ convulsiones ___
mareos ___ ¿Qué edad tenía el niño? ¿Cómo fue atendido?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Operaciones SI / NO ¿Cuáles? ¿Por qué?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Exámenes realizados (neurológico, audiológico, psiquiátrico, psicológico u otros)
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Resultados______________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

º7
 _______________________________________________________________________
_______________________________________________________________________

V. HISTORIA DEL DESARROLLO NEUROMUSUCLAR

 Edades para:
Levantar la cabeza _______ sentarse (sin ayuda) _____ gatear _____ pararse (sin
ayuda) ______ y caminar
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Dificultades, tendencia a caerse o golpearse SI / NO
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Presencia de movimientos automáticos: balancearse _____ ¿otros?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________
Movimiento agitados: sacude los brazos _____ estruja las manos ___ ¿en qué
momento? ¿Con que frecuencia?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Habilidades para correr ____ saltar ___ pararse sobre un pie ____ desplazarse
saltando sobre un pie
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

º8
  Dominancia lateral manual IZQUIERDA / DERECHA
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

VI. HISTORIA DE LA HABILDIAD PARA HABLAR

1.- HABLA

 ¿a qué edad su hijo balbuceo? ____ ¿las primeras palabras?____ ¿Cuáles?

_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______
 ¿de qué manera se hace entender Ud., por us hijo? (gestos ___ gritos ____ hablando
___ llevando de la mano ____ balbuceando ____ otros: _____ ¿con que frecuencia
utiliza el habla
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Dificultades para pronunciar (omisión ____, sustitución ___ distorsión de fonemas
___) ¿Cómo es su pronunciación, se entiende, articulación trabada?
Describir_______________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 ¿Cuántas palabras decía al año? ___ ¿Cuántas palabras decía al año y seis meses? ___
¿Cuántas palabras decía a los dos años?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

º9
 ¿Cuándo empezó a utilizar frases de 2 palabras? ____ ¿de tres?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Reacción cuando se le llama por su nombre
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 ¿se le entiende bien cuando habla en casa? SI / NO ¿con otros niños? SI / NO ¿Cómo
los familiares? SI / NO
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 ¿la sonrisa tiene valor comunicativo? SI / NO ¿la expresión facial? SI / NO ¿responde
cuando se le habla? SI / NO
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Habla demasiado, rápido ____, lento _____, normal
 ¿su voz es normal ___ alterado ____? ¿de qué tipo? ¿grito al hablar?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

º10
 _______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

2º MOVIMIENTOS DE LA ZONA ORAL

 Uso del biberón, consumo de alimentos líquidos, pastosos y solidos ¿Cómo bien? ¿Qué
come con más frecuencia?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Masticación (hábitos de masticación: morder objetos, onicofagia, bruxismo) ¿come
con los labios cerraos o abiertos?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Oclusión (buena ___ mala ____) ¿recibe tratamiento ortodoncico ___ u odontológico
_______________________________________________________________________
 Babea: ¿al dormir, comer, en todo momento ¿ SI / NO
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Dificultades para respirar (enfermedades a la vía respiratoria, alergias, resfriados
frecuentes, asma, etc.)
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

º11
 _______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Dificultades en los movimiento de la boca SI / NO
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

VII FORMACION DE HABITOS

1.- ALIMENTACION

 Lactancia recibió hijo ¿materna? ____ artificial _____ ¿durante cuánto tiempo lo
recibió?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 ¿a qué edad aparición los primeros dientes a su hijo? ___ empezó a darle alimentos
solidos?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Habilidades para comer, ¿requiere ayuda? SI / NO ¿usa cubiertos? SI / NO
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

º12
 _______________________________________________________________________
_______________________________________________________________________
 ¿su hijo tiene apetito? SI / NO ¿cuantas comidas recibe al día? __ ¿Cómo son? ¿Por
qué?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

2.- HIGIENE

 ¿a qué edad su hijo comenzó a controlar la orina? (diurna – nocturna?

_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 ¿su hijo, pide cuando quiere hacer sus necesidades? SI / NO
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 ¿su hijo se asea solo? SI / NO, si, requiere ayuda ¿Cómo?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

º13
3.- SUEÑO

 Sueño. Duración ___ usa de medicamentos (edad, frecuencia)

_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Temores nocturnos
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 ¿ cuándo su hijo está dormido: habla___ grita___ se mueve ____ transpira ___ camina
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 ¿se resiste a acostarse a un horario determinado? SI / NO ¿a qué hora?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

4.- INDEPENCIA PERSONAL

 ¿su hijo hace mandados? __ ¿dentro del hogar?__ ¿ fuera del hogar? (barrio)
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

º14
 _______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 ¿su hijo ayuda en casa? ___ ¿Qué hace? ¿tiene responsabilidades?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Disciplina en el hogar: existencia de normas, castigos y premios, quienes lo ejecutan.
¿es constante?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Independencia para vestirse, atarse los zapatos, otros
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

VII CONDUCTA

 Conductas adaptativas
¿Se come las uñas ? SI / NO
¿Se succiona los dedos? SI / NO
¿Se muerde el labio? SI / NO
¿Le sudan las manos? SI / NO
¿Le tiemblan las manos y piernas? SI / NO
¿Agrede a la personas sin motivo? SI / NO
¿Se le caen las cosas con facilidad? SI / NO

º15
  Problemas de alimentación __ sueño____ concentración ___ indisciplina (irritabilidad,
hiperactividad) ____, otros
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Carácter del niño
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

IX JUEGO

 ¿su hijo juega solo? __ ¿Por qué?__ ¿dirige o es dirigido?

_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 ¿qué juegos prefiere su hijo? ¿Cuáles son sus juguetes preferidos?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________
 ¿prefiere jugar con niños de su edad, con mayores o niños menores a su edad?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

º16
 _______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 ¿Cuáles son las distracciones principales de su hijo? Uso del tiempo libre, deportes
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Conductas en el juego con otros niños: agresividad, ausencia del deseo del contacto
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

X HISTORIA EDUCATIVA

 Inicial: edad __, adaptación __

dificultades_____________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
__
 Primaria, secundaria: edad, rendimiento, dificultades (especificar), nivel de
adaptación_____________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

º17
 _______________________________________________________________________
_______________________________________________________________________
 Cambios en el colegio. __ ¿Por qué?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 ¿observo dificultades en el aprendizaje? __ ¿desde cuándo? ¿Qué hizo? Rendimientos
en las escritura, lectura y
matemáticas____________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Repotencias __ ¿Cuántas veces?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Conducta en clase. Asignatura que más domina, asignatura que menos
domina________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
______________________________________________________________________
 Opinión de parte del niño, hacia el colegio, hacia el profesor, de sus compañeras, de
las tareas
_______________________________________________________________________
_______________________________________________________________________

º18
 _______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Opinión del profesor
¿Ha recibido algún servicio especial? Logopedia __ refuerzos __ ¿desde cuándo?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

XI PSICOSEXUALIDAD

 ¿a qué edad hizo preguntas su hijo, sobre sexo y procreación? Información que se le
brindo, ¿Cómo?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 ¿tiene amigos (as) del sexo opuesto?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 ¿su hijo presenta conductas como tocarse o sobarse los genitales? SI _ NO _ frecuencia
y en que circunstancias
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

º19
 _______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

XII OPINION Y ACTITUDES DE LSO PADRES CON LA RELACION AL HIJO

 Reacción de los padres: rechazo __ vergüenza __ indiferencia __ aceptación __

preocupación_
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Creencias sobre el problema, sentimientos de culpa, etc
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Cambios: aislarlo o dejarlo con el grupo, exigirle un comportamiento similar, mayor
atención, sobreprotección
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Uso del castigo: ¿Cómo, con qué frecuencia? Reacción del niño
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

º20
 _______________________________________________________________________
_______________________________________________________________
 Comportamiento del niño con los padres, hermanos, amigos, otros. Apego del niño
¿hacia quién?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

XIII ANTECEDENTES FAMILIARES

 SI / NO (especificar enfermedades psiquiátricas, problemas del habla, dificultades en el

aprendizaje, epilepsias, convulsiones, retardo mental, otros)
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
 Carácter de los padres. Relación de pareja
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

º21