ANAMNESIS ADULTOS

1. Antecedentes personales

Nombre:
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Fecha de nacimiento: _______________________ Edad:
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Escolaridad:
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Ocupacin previa y actual:
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Estado civil: ______________________________ Hijos:
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Con quin vive:
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Lateralidad: ______________________________ Idiomas: ____________________________
Direccin: ________________________________________________________________________
Telfono de contacto: ______________________________________________________________
Evaluador: _______________________________ Fecha evaluacin: ____________________

Motivo de consulta:
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Mdico que deriva: ________________________________________________________________

Hobbies:
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Actividades sociales: _______________________________________________________________
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Otros: ___________________________________________________________________________
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2. Antecedentes Mdicos importantes

Estado de alerta: __________________________________________________________________

Diagnsticos: _____________________________________________________________________
Cirugas: _________________________________________________________________________
Hospitalizaciones: _________________________________________________________________
Medicamentos: ___________________________________________________________________
Apoyo respiratorio: ________________________________________________________________
Enfermedades neurolgicas: _________________________________________________________
Evaluacin por otros profesionales: ___________________________________________________
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ACV
Fecha del accidente: _______________________________________________________________
Antecedentes de accidentes vasculares previos: _________________________________________
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Descripcin breve del episodio (cmo debut el paciente): ________________________________

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Diagnstico topogrfico: ____________________________________________________________

Diagnstico sindromtico: __________________________________________________________
Diagnstico etiolgico: _____________________________________________________________

TEC
Fecha del accidente: _______________________________________________________________
Mecanismo: ______________________________________________________________________
Diagnsticos mdicos: ______________________________________________________________
Diagnsticos neurolgicos: __________________________________________________________
Evolucin del mismo: ______________________________________________________________
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Datos de APT: ________________________________________GCS: __________________

DEMENCIA
Fecha del diagnstico: ______________________________________________________________
Especialidad mdica que diagnostica: _________________________________________________
Informante (familiar, cuidador, otro): _________________________________________________
Percepcin del usuario: _____________________________________________________________
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3. Observaciones de la Evaluacin:
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