DOCENTES: Mg. Ps. Luisa Badillo Maldonado
ANAMNESIS
NINOS
1 DATOS GENERALES
1. Nombre:
2. Bdad Sexo
3. Fecla y lugar de nacimiento:
eee ee
4. Grado de escolaridad: __ Tumno:
oes ae siromeiterpdecieeiafetes novi OI fi
5. Institucién Educativa: 2 =
6. Lugar que ocupa en la familia
7. Domicilio Actua SS
8. Teléfono:
9. Informante:
10, Eotrevistador:
11, Fecha de la entrevista
ie etree
Tl, MOTIVO DE CONSULTA
* {Cuil es Ia dificultad de su nitio(a)?
+ Desde cuando lo notaron?
+ {Cémo se presenta? EI nifio(a) se da cuenta de su dificultad?
{Las dificultades del niffo originan problemas con otras personas?
1Qué tipo de problemas?
(Del 01 al 10 cémo catalogaria el problema de su nifio(a)?
. ANTECEDENTES DEL PROBLEMA
(Por qué cree Ud. que se originé el problema?
Factores:
Orgénicos (/) Hereditarios (.) Ambientales ( ) — Psicolégicos ( )
Otros (Especifique cuales) .
dH recibido algiin tipo de tratamiento anteriormente?
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