ANAMNESIS

I. DATOS INFORMATIVOS:

Nombres y Apellidos: …………………………………………………………………………………..

Lugar y Fecha de Nacimiento: …………………………………………………………………………………..
Edad: …………………………………………………………………………………..
Sexo: Masculino: (………) Femenino: (……..)
Escolaridad: …………………………………………………………………………………..
C.E Procedencia: …………………………………………………………………………………..
Nombre de la Madre: …………………………………………………………………………………..
Instrucción …………………………………… Ocupación: …………………….
Nombre del Padre: …………………………………………………………………………………..
Instrucción: ……………………………………………………………………………………..
Estado Civil de los padres: …………………………………………………………………………………..
Nro. Hermanos (Edad y Escolaridad): Edad:………. Sexo:……… Escolaridad:………………..……
Edad:………. Sexo:……… Escolaridad:………………..……
Edad:………. Sexo:……… Escolaridad:………………..……
Edad:………. Sexo:……… Escolaridad:………………..……
Domicilio: ……………………………………………………………………………………..
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Vive con ……………………………………………………………………………………..
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Teléfono: ……………………………………………………………………………………..
Derivado por: ……………………………………………………………………………………..
Fecha de Entrevista: ……………………………………………………………………………………..

II. MOTIVO DE CONSULTA Informante:..................................

Problema de Lenguaje (……….) Problema del Habla (……….)

Problema de Aprendizaje (……….) Trastorno. de Conducta (……….)
Déficit de Atención (……….) Otros: (……….)

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III. ANTECEDENTES:

a. FAMILIARES:
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b. PERSONALES:
PRE NATALES:
Tto. de fertilidad / deseado / Nro. de gestación
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Control Pre Natal Si ( ) No ( ) ...........................................................

Complicaciones:
Tabaco / Alcohol / Drogas / Rx / Infecciones: citomegalovirus – rubeola – toxoplasmosis /
Hiperémesis gravídica / Amenaza de aborto / Traumatismos / Maniobras abortivas/ Preclampsia /
Eclampsia / Ruptura prematura de membrana/ Hipotiroidismo / Hipertiroidismo / Diabetes
mellitus/ Qx / Anemia / Transfusiones / Intoxicaciones / Factor RH / Cardiopatía / Heredopatía /
SIDA / Otros
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PERI NATALES:

Parto: Prematuro ( ) Término ( ) Post Maduro ( )

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Trabajo de parto: Espontáneo (….) Inducido (….) Atención:……………………………
Tipo de Atención: Hospitalaria (.…) Domiciliaria (….) Circular de cordón (….)
Tipo de Parto: Eutócico (….) Distócico (….)
Instrumentación: Fórceps (….) Vácum (….)
Anestesia: Electiva (.…) Emergencia (….)
Cesárea (tipo de anestesia – motivo):........................................................................................
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Sufrimiento fetal:...........................................................................................................................

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POST NATALES:

Llanto: Tardío (….) Débil (….) Ausente (….) Estimulado (….)

Respiración: Normal (….) Inducida (….) Oxígeno: (….)
Peso: ……………………………………….. Talla: ………………………………………
Color de piel: Cianosis (….) Palidez (….) Rubicundez (….)
Apgar: Al 1’ ……….. A los 5’ …………. A los 10’ ………..
Macrocefalia: (….) Microcefalia (….) Hidrocefalia (….)
Succión: Alterada (….) Normal (….)
Incubadora:........................................................................................................................................
Malformación congénita:………………………………………………………………………………………………………………………..

Complicaciones:
Digestivas / convulsiones / temor o sobresaltos / ictericia / hipoglicemia / cianosis persistente / asfixia /
distress respiratorio / sepsis / coma / hipoactividad / hiperactividad/ hipersomnia / insomnio / parálisis /
transfusiones / incompatibilidad Rh/ Eruptivas / Traumatismos / Otros
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Tratamientos: (Medicamentoso – Rehabilitación)
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Hospitalización:Si ( ) No ( ) Tiempo:.......................................

DATOS DE DESARROLLO

Desarrollo Psicomotor:
Bipedestación:…………………………….……….. Marcha:………………………………………………….…..
Dominio Manual: Diestro: ( ) Zurdo ( ) Ambidextro ( )
Sialorrea: SI ( ) NO ( )

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Lenguaje:
Balbuceo:…………………………………….……………. Palabras:………………………………………………………..…..
Frases:…………………………………….……………..…. Oraciones:………………………………………………………..…..

Dificultades de Lenguaje – Evolución:...................................................................................

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Posibles razones a que se atribuyen las dificultades:..............................................................

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Control de Esfínteres: Vesical:.................................. Anal:............................................

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Dificultades:.............................................................................................................................
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Desarrollo Perceptual:

Visión:.................................................................................................................................

Audición:
Al Sonido: Si ( ) No ( )
Reacción a voz susurrada: Si ( ) No ( )

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Área Personal Social:

Actividades de la vida diaria:

Alimentación: ……………………………………………………………………………..…………………….……………....
Vestido:....................................................................................................................................
Higiene:....................................................................................................................................
Sueño:......................................................................................................................................
Apetito:....................................................................................................................................
Conducta:.................................................................................................................................
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Hábitos Nerviosos:

Onicofagia ( ) Hiperhidrosis palmar ( ) Tics ( )

Fobias ( ) Pica ( ) Enuresis ( )
Sincinesias ( ) Tricotilomanía ( ) Otros: ( )

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Manejo conductual del medio:

Sobreprotección ( ) Indiferencia ( ) Ambivalencia ( ) Castigo ( )

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Socialización:
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Dinámica Familiar:

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Vivienda: ..................................................................................................................................

Escolaridad: (Evaluaciones – Tratamiento) (Rendimiento-Conducta-Adaptación)

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