Anamnesis

1. DATOS PERSONALES

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Edad:___________________________________________________________

Fecha de nacimiento: ___________________________________________________________

Lugar de nacimiento: ___________________________________________________________

Sexo: ___________________________________________________________

Centro de estudios: ___________________________________________________________

Grado de Instruccin: ___________________________________________________________

Direccin: ___________________________________________________________

Telfono: ___________________________________________________________

Fecha de consulta: ___________________________________________________________

2. PROBLEMA ACTUAL___________________________________________________________________

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OBSERVACIONES:___________________________________________________________________

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3. HISTORIA FAMILIAR

PADRE

Datos Generales

Nombre: ________________________________________________

Edad: ________________________________________________

Grado de Instruccin: ________________________________________________

Centro de Labores: ________________________________________________

Telfono: ________________________________________________

Carcter

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Enfermedades

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MADRE

Datos Generales

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Edad: ________________________________________________

Grado de Instruccin: ________________________________________________

Centro de Labores: ________________________________________________

Telfono: ________________________________________________

Carcter

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Enfermedades

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HERMANOS

Datos Generales

Nombre: ________________________________________________

Edad: ________________________________________________

Grado de Instruccin: ________________________________________________

Centro de Labores: ________________________________________________

Telfono: ________________________________________________

Carcter

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Enfermedades

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HERMANOS

Datos Generales

Nombre: ________________________________________________

Edad: ________________________________________________

Grado de Instruccin: ________________________________________________

Centro de Labores: ________________________________________________

Telfono: ________________________________________________

Carcter

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Enfermedades

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HERMANOS

Datos Generales

Nombre: ________________________________________________

Edad: ________________________________________________

Grado de Instruccin: ________________________________________________

Centro de Labores: ________________________________________________

Telfono: ________________________________________________

Carcter ________________________________________________________________________________________

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Enfermedades

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HERMANOS

Datos Generales

Nombre: ________________________________________________

Edad: ________________________________________________

Grado de Instruccin: ________________________________________________

Centro de Labores: ________________________________________________

Telfono: ________________________________________________

Carcter

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Enfermedades

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HERMANOS

Datos Generales

Nombre: ________________________________________________

Edad: ________________________________________________

Grado de Instruccin: ________________________________________________

Centro de Labores: ________________________________________________

Telfono: ________________________________________________

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Carcter

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Enfermedades

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ABUELOS PATERNOS

Datos Generales

Nombre: ________________________________________________

Edad: ________________________________________________

Grado de Instruccin: ________________________________________________

Centro de Labores: ________________________________________________

Telfono: ________________________________________________

Carcter

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Enfermedades

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ABUELOS PATERNOS

Datos Generales

Nombre: ________________________________________________

Edad: ________________________________________________

Grado de Instruccin: ________________________________________________

Centro de Labores: ________________________________________________

Telfono: ________________________________________________

Carcter

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Enfermedades

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ABUELOS MATERNOS

Datos Generales

Nombre: ________________________________________________

Edad: ________________________________________________

Grado de Instruccin: ________________________________________________

Centro de Labores: ________________________________________________

Telfono: ________________________________________________

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Carcter

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Enfermedades

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ABUELOS MATERNOS

Datos Generales

Nombre: ________________________________________________

Edad: ________________________________________________

Grado de Instruccin: ________________________________________________

Centro de Labores: ________________________________________________

Telfono: ________________________________________________

Carcter

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Enfermedades

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NIERA O SUSTITUTO

Datos Generales

Nombre: ________________________________________________

Edad: ________________________________________________

Grado de Instruccin: ________________________________________________

Centro de Labores: ________________________________________________

Telfono: ________________________________________________

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Carcter

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Enfermedades

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ACTITUDES DEL NIO RESPECTO LA FAMILIA

Comportamiento del nio con los padres

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Comportamiento del nio con los hermanos

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Adaptacin al hogar

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Area de inadaptacin

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ACTITUDES DE LOS PADRES HACIA EL NIO

Actitud del Padre

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Actitud de la madre

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Modo de sancin

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Actitud frente a la crianza

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Expectativas frente al nio

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4. AMBIENTE FAMILIAR

Carcter del ambiente

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Problemas

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5. HISTORIAL PERSONAL

Embarazo

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Nacimiento

Parto

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Actitudes

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Alimentacin

Actitudes

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Problemas

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Sueo

Hbitos

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Alteraciones

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Desarrollo Motor

Evolucin

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Problemas de lenguaje

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Desarrollo Emocional

Afectividad

Personal

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Animales

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Relaciones emocionales

Frustracin

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Estrs

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Castigo

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Hostilidad de otros

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Temores y estados ansiedad

Grado de independencia

Animo prevalente

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Grado adaptacin

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Sntomas neurticos

Enuresis

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Onicofagia

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Otros

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Desarrollo Social

Relaciones con los adultos

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Relaciones con nios

Mayores

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Menores

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De su edad

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Grado de colaboracin

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Grado de generosidad

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Adaptacin general

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Perturbaciones

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6. ETAPA ESCOLAR

Pre Escolar

Adaptacin

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Primaria

Rendimiento

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Adaptacin

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Area del problema

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Secundaria

Rendimiento

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Adaptacin

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Area del problema

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Desarrollo Social en la escuela

Relacin con los profesores

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Relacin con los compaeros

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Disciplina

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Responsabilidad

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Otros estudios

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7. HABITOS E INTERESES

Escolares

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Extra escolares

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Ldicos

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Sociales

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Religiosos

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8. DESARROLLO SEXUAL

Primeros intereses

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Masturbacin

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Enamoramientos

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Relaciones Sexuales

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9. ENFERMEDADES Y ACCIDENTES

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10. CAMBIOS DE RESIDENCIA

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INFORMANTE

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