ANAMNESIS NIÑOS

I. Datos de Filiación

Nombre : _________________________________________
Edad : _________________________________________
Sexo : _________________________________________
Lugar y Fecha de Nacimiento : _________________________________________
Colegio : _________________________________________
Grado : _________________________________________
Religión : _________________________________________
Composición Familiar : _________________________________________
Dirección : _________________________________________
Referido : _________________________________________

II. Datos de la entrevista

Personas entrevistadas : _________________________________________

Atendido por : _________________________________________
Lugar de evaluación : _________________________________________

III. Motivo de Consulta

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IIII. Datos familiares

III.1. Datos del Padre:

Nombre : _______________________
Edad : _______________________
Lugar y fecha de nacimiento : _______________________
Estado civil : _______________________
Grado de instrucción : _______________________
Ocupación Actual : _______________________

III.2. Datos de la Madre

Nombre : _______________________
Edad : _______________________
Lugar y fecha de nacimiento : _______________________
Estado civil : _______________________
Grado de Instrucción : _______________________
Ocupación Actual : _______________________

III.3. Datos de los hermanos (de c/u)

Nombre : _______________________
Edad : _______________________
Lugar y fecha de nacimiento : _______________________
Estado civil : _______________________
Grado de Instrucción : _______________________
Ocupación actual : _______________________
Salud : _______________________

Nombre : _______________________
Edad : _______________________
Lugar y fecha de nacimiento : _______________________
Estado civil : _______________________
Grado de Instrucción : _______________________
Ocupación actual : _______________________
Salud : _______________________

Nombre : _______________________
Edad : _______________________
Lugar y fecha de nacimiento : _______________________
Estado civil : _______________________
Grado de Instrucción : _______________________
Ocupación actual : _______________________
Salud : _______________________

Nombre : _______________________
Edad : _______________________
Lugar y fecha de nacimiento : _______________________
Estado civil : _______________________
Grado de Instrucción : _______________________
Ocupación actual : _______________________
 Salud : _______________________

III.4. Datos de la pareja

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Antecedentes Médicos.

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Enfermedades mentales:

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Enfermedades Hereditarias
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Antecedentes de dificultades escolares:

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VI. Periodo Prenatal y Perinatal:

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VII. Historia del Desarrollo del Niño

7.1 Alimentación:
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7.2 Sueño:
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7. 3. Cuidado del niño:

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7.4. Desarrollo Psicomotor:

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7.5. Control de Esfínteres:

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7.6. Desarrollo del lenguaje

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7.7 ¿Cómo describiría a su hija?

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7.8 Desarrollo socioemocional:

Disciplina y límites:
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Hábitos
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Miedo
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Pataletas
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Relación con los padres:

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Juego:
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Televisión:
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Reacción frente los cambios:

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Información sobre sexualidad:

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VIII. HISTORIA DE LA SALUD

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IX. HISTORIA EDUCACIONAL:

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X. VIDA COTIDIANA:
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