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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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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