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 Antecedentes personales

Nombre:

Fecha de nacimiento:

Edad actual

Escolaridad

Colegio

Domicilio

Teléfono

 Antecedentes familiares

Nombre de la madre

Nivel educacional

Ocupación

Nombre del padre

Nivel educacional

Ocupación

Nombre del cuidador

Nivel educacional

Ocupación

Hermanos (especificar nombre y edad)

Personas con las que vive

 Motivo de consulta :
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 Antecedentes pre-natales

Enfermedades del feto o de la madre


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Uso de medicamento u otras sustancias

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 Antecedentes peri-natales

Parto:________________________________Tiempo de gestación__________________________

Peso:__________________________ Talla: ___________________ Apgar: __________________

Complicaciones o enfermedades del


neonato:_________________________________________________________________________
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 Antecedentes post- natales:

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 Antecedentes mórbidos relevantes del niño/a

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Evaluación o tratamiento de otros profesionales

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 Antecedentes Mórbidos relevantes familiares

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 Antecedentes del desarrollo

Psicomotor: Control cefálico………………………………. Sedestación………………………………………..

Gateo…………………………… Bipedestación………………………………….. Marcha………………………..

Control de esfínteres: Diurno…………………………………. Nocturno……………………………………..


Lingüístico-comunicativo:
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Afectivo- social:
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Juego:

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Integración sensorial:

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 Antecedentes de malos hábitos orales:


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 Antecedentes escolares:
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 Intereses del niño /a:
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Observaciones:
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