FICHA CLNICA INTEGRADA - ANAMNESIS

Fechas de
aplicacin:
I.

IDENTIFICACIN:

Nombre Completo:
____________________________________________________________________
Fecha de nacimiento: ___________________________________ Edad:
_________________________
II. MOTIVO DE CONSULTA:
Motivo de consulta del joven:
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_______________________

Motivo de consulta de la familia o adulto significativo:

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_______________________

Expectativas de tratamiento del joven:

___________________________________________________

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_____________

Expectativas de tratamiento de la familia o adulto significativo:

_____________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________

Simbolizacin de contexto obligado (si

corresponde):________________________________________
________________________________________________________________________________
____

III. DESCRIPCIN DE LA PROBLEMTICA ACTUAL:

Desde el
joven:_______________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
_____________

De la familia:
________________________________________________________________________

________________________________________________________________________________
________________________________________________________________________________
_____________

IV. ANAMNESIS:
a) Antecedentes Prenatales:
Nmero de embarazos:
_________________________________________________________________
Dificultades para concebir:
_______________________________________________________________
Planificacin del embarazo:
______________________________________________________________
Respuesta emocional frente embarazo:
______________________________________________________
________________________________________________________________________________
_____
Deseos, intentos y/o abortos:
_____________________________________________________________
________________________________________________________________________________
_____

b) Antecedentes Perinatales:
Normal

Anormal

Controles de
embarazo

Si

No

ARO

Si

No

Embarazo

Observaciones

Sntomas de
prdida

Si

No

Ecografas

Si

No

Consumo
Medicamentos
en gestacin

Si

No

Parto

Vaginal

Cesrea

Peso:

Apgar

Si

No

Valor:

Compaa

Si

No

Quin?:

Patologa
perinatal

Si

No

Cul?:

kg.

Talla:

cm.

/10

c) Antecedentes Postnatales:
Diagnstico Depresin Post Parto

Si

No

Controles Peditricos

Si

No

Vacunas

Si

No
Si

Lactancia

No

1/3 meses ----- 4/6 meses ----- 7/12 meses ----- 13/18meses ----- 19/24meses ----- Ms de 2
aos -----

Consumo medicamentos en lactancia

Alimentacin

Normal

Si

Anormal

Transicin de pecho a mamadera y de mamadera a slidos:

_____________________________________

No

________________________________________________________________________________
_____
Periodo de denticin:
___________________________________________________________________
________________________________________________________________________________
_____
Sueo

Normal

Anormal

Alteraciones:
__________________________________________________________________________

Desarrollo
Psicomotor

Normal

Anormal

Rabietas

Si

No

Estimulacin:
_________________________________________________________________________
Desarrollo del
Lenguaje

Normal

Anormal

Estimulacin:
_________________________________________________________________________
Control de
Esfnter

Normal

Anormal

Diurno (18-24m): __________________________ Nocturno (30- 36m):

___________________________

Entrenamiento:
________________________________________________________________________
Recadas:
_____________________________________________________________________________
PATRN DE APEGO:
______________________________________________________________________
________________________________________________________________________________
__________
________________________________________________________________________________
__________
Antecedentes del Desarrollo Psicosexual:
Desarrollo sexual primario y secundario: ___________________________________________________
________________________________________________________________________________
_____
Conductas Inadecuadas:
________________________________________________________________
________________________________________________________________________________
_____
Actitud familia: _______________________________________________________________________
________________________________________________________________________________
_____
Impacto contexto habitacional: ______________________________________________________
________________________________________________________________________________
_____

Antecedentes Escolares:
Edad
Ingreso
a Jardn
Edad
Ingreso
a Kinder
Edad
Ingreso
a Colegio
Repitencias

Si

No

Cambios de
establecimiento

Si

No

Desercin
Escolar

Si

No

Educacin No
Formal

No

Trastorno de
Aprendizaje

Si

No

Desarrollo Social Escolar: ______________________________________________________________

________________________________________________________________________________
_____

Antecedentes
Mrbidos
(Hospitalizaciones,
cadas, golpes,
accidentes y
enfermedades)

Si

No

V. ANTECEDENTES DE TRATAMIENTOS EN ESPECIALIDADES MDICAS:

EDA
D

LUGAR

MOTIVO

DURACIN

FINALIZ
A

Psicologa

Neurolog
a
Psiquiatr
a
Nutricioni
sta
Otro

VI. ANTECEDENTES DE TRATAMIENTOS DE DROGAS:

EDAD

DURACIN

FINALIZA

APS
PAI
PR
(CT ---)
UHCE
PAC
OTRO

VII. ANTECEDENTES DE INSTITUCIONALIZACIN:

SI
DEPRODE

NO

FECHA

INTITUCIN

DEDEREJ

VIII.

MEDIDA
MEDIO
LIBRE

PSA
MCA
SBC
PLA
PLE
CSC

-------------------------

MEDIDA
PRIVATIVA
DE
LIBERTAD

GENCHI
COD
CERECO
CIP
CRC

------------------------

ANTECEDENTES DE VULNERACIONES:

Si
Problemas econmicos.
Problemas habitacionales.
Problemas de acceso a servicios de salud y otros servicios.
Negligencia parental
Abandono parental
Maltrato fsico
Maltrato psicolgico
Abuso sexual
Violencia Intrafamiliar
Peores formas de trabajo infantil
Explotacin sexual, comercial infantil

IX.

OBSERVACIN CLNICA

No

rea Intelectual
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rea Emocional
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rea de las Relaciones Interpersonales

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Contexto Sociocultural e Infraccin de ley
________________________________________________________________________________
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_____________________________________________________
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X.

ANTECEDENTES FAMILIARES

Funcionamiento familiar temprano y actual (Relaciones, lmites, normas, autoridad,

parentalidad, roles, mitos e hitos familiares)
________________________________________________________________________________
________________________________________________________________________________

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Fecha

Profesional Responsable

Firma