Fonoaudiologa

Ficha FA: _________

N Historia; ________
FICHA FONOAUDIOLOGICA

I. ANTECEDENTES PERSONALES:
Nombre:____________________________________________________Fecha:_______________________
Fecha de Nacimiento:____________________________Edad:________ Telfono (s):___________________
Domicilio: _______________________________________________________________________________
Escolaridad: ___________________________________ Profesin:____________ Nacionalidad: __________
Estado Civil:________________________________ ___ Hijos: ____________________________________
Idiomas que Habla: _______________________________________________ Lateralidad: ______________
Hospitalizado: __________________________________ Ambulatorio: ______________________________
Trastornos FA Premrbidos:_________________________________________________________________
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II. ANTECEDENTES PSQUICOS:
Premrbidos:_____________________________________________________________________________
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Postmrbidos: ____________________________________________________________________________
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III. ANTECEDENTES SOCIOECONMICOS:
(situacin laboral, previsin):_________________________________________________________________
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IV. OTROS ANTECEDENTES:
Informante: _____________________ Referido por: ____________________ Examinador: _______________
Observaciones: ___________________________________________________________________________
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V. ANTECEDENTES CLINICOS:
Historia clnica (fecha de inicio): ______________________________________________________________
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Diagnsticos:_____________________________________________________________________________
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Otros antecedentes:________________________________________________________________________
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