ANAMNESIS

ANTECEDENTES PERSONALES
Nombre:
________________________________________________________________________
Fecha de Nacimiento: __________________________ Edad:
_______________________________
Domicilio:
________________________________________________________________________
Escolaridad: ____________________________ Fecha de evaluacin:
________________________
Persona a cargo: _______________________________ Parentesco:
_________________________
MOTIVO DE CONSULTA:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
ANTECEDENTES PRE- PERI- POST NATALES
Embarazo Planificado: _________________ Numero de Embarazo
_________________________
Estado nutricional:
________________________________________________________________
Estado emocional:
________________________________________________________________
Complicaciones durante embarazo
___________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Ingesta de Frmacos durante el embarazo:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

Semanas de gestacin:
40/S
Parto:
Frceps

Normal

Menos 36/S
/

Cesrea

36/S
/

38/S -

40/S

Cesrea de urgencia

Mas
/

Duracin del trabajo de parto:

_______________________________________________________

Complicaciones durante el parto:

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Incubadora: __________________________Cuanto tiempo:
_______________________________
Tratamientos posteriores al parto:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Caractersticas del recin nacido:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Peso: ________________ Talla: _____________________ Circunferencia:
____________________

DESARROLLO PSICOMOTOR
Control Ceflico: ____________ A qu edad:
___________________________________________
Sedestacin: _______________ A qu Edad:
____________________________________________
Gateo: ____________________A qu Edad:
____________________________________________
Marcha sin apoyo: _________ _A qu Edad:
____________________________________________

Control de Esfnter: Diurno______________ A qu Edad:

__________________________________
Nocturno____________ A qu Edad:
_________________________________

ANTECEDENTES MORBIDOS DEL MENOR

Resfros Frecuentes:
_______________________________________________________________
Bronquitis Obstructivas:
____________________________________________________________
Amigdalitis:
______________________________________________________________________
Alergias:
________________________________________________________________________
Intervencin Quirrgicas:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Hospitalizaciones: ____________ Porque: ____
_________________________________________
cuanto tiempo:
___________________________________________________________________
Enfermedades Importantes:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Alteracin de Visin: ____________ Cual:
______________________________________________
Usa lentes: ______________________ hace cunto
tiempo:_______________________________
Alteraciones Auditivas: ___________ Cual:
_____________________________________________

Usa audfonos: ___________________ Hace cunto tiempo:

_______________________________
Alteracin de habla: ______________ Cual:
____________________________________________
Trastorno del lenguaje: ____________ Cual:
____________________________________________
Trastornos de la deglucin: ________ Cual:
_____________________________________________

ANTECEDENTES FAMILIARES
Nombre Padre: ______________________________________________ Edad:
________________
Escolarizacin: ____________________ Ocupacin:
______________________________________
Nombre Madre: _____________________________________________ Edad:
________________
Escolarizacin: ____________________ Ocupacin:
______________________________________
Antecedentes Mrbidos Familiares:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

DESARROLLO DEL LENGUAJE

Presencia de:
Sonrisa Social: ______________ Gorjeo: _________________ Balbuceo:
_____________________
Primeras palabras: Edad: ___________ Cuantas: _____________ Cuales:
________________________________________________________________________________
________________________________________________________________________________
Frases (dos palabras) : Edad__________ Cuantas:
_______________________________________

Lenguaje Verbal: ____________ Lenguaje No Verbal:

_____________________________________

EVALUACION/DIAGNOSTICO DE OTROS PROFESIONALES

Kinesiologa
______________________________________________________________________
Terapia
Ocupacional_______________________________________________________________
Psicologia______________________________________________________________________
__
Neurologo______________________________________________________________________
__
OTROS_________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
__
OBSERVACIONES
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