Anamnesis Format

Personal background:
Student's name:
Date of birth: Age:
Address:

Family history:
Name of parent:
Occupation: Age:
Schooling: Work:
Mother's name:
Occupation: Age:
Schooling: Work:
No. Of children: Place occupied by the student:
Person with whom you live:
Responsible person:

Prenatal history:
Maternal diseases:
Medications (which ones):
Falls: Symptoms of miscarriage:
Nutritional status:
Emotional state:

Perinatal history:
Delivery: Weight: Size: Apt:
Problems during childbirth (which ones):

Postnatal history:
Postpartum treatments:
Major illnesses: Encephalitis: Meningitis:
Poliomyelitis: Tuberculosis: Hepatitis:
Operations - Hospitalizations (time):
Has suffered: Loss of consciousness:
Vision problems: Which ones? Wear glasses:
Hearing problems: Which ones?

Psychomotor Development: at what age?

I control my head: He sat down:
Stopped: Road:
I control sphincters:

Language development: at what age?

He said words: He said phrases:
Said prayers: I speak spontaneously:
 Understood instructions:

Has needed evaluation: Psychological: when:

Neurological: when:
Psychiatric: when:
Psychopedagogical: when:

Habits
How many hours do you sleep:
He has trouble sleeping:
Possesses study habits:
What you entertain yourself with:
How many hours a day do you dedicate to the game:

Family relationships:
How is your relationship with your mother:
Father:
Siblings:
Other family members:

María Griselda Pimentel Sarmiento.

Educational Sciences with a major in Educational Psychology.
8vo. Semester "A".
October 23 - 2011.