ANAMNESIS

I.- IDENTIFICACION
NOMBRE:_____________________________________________________________
FECHA DE NACIMIENTO:______________________ EDAD: __________________
DIRECCION: _________________________________ COMUNA: _______________
TELEFONO: ________________ FECHA DE EVALUACION: __________________
EXAMINADORA: ______________________________________________________
MOTIVO DE CONSULTA: _______________________________________________
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II.- ANTECEDENTES FAMILIARES
INTEGRANTES FAMILIA NUCLEAR: _____________________________________
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CON QUIEN VIVE ACTUALMENTE: ______________________________________
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HERENCIA FAMILIAR EN RELACION AL PROBLEMA: _____________________
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II.- ANTECEDENTES MORBIDOS
ANTECEDENTES DEL EMBARAZO, DEL PARTO (APGAR AL MINUTO) Y
POSTNATAL: __________________________________________________________
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TIEMPO DE AMAMANTAMIENTO:
SI:____

NO:___

CUNTO TIEMPO?: ____________________________

CONTROL DE ESFINTER:
SI: ____

NO: ___

CUNDO?: ___________________________________

MALOS HABITOS ORALES:

Si

No

Desde

Hasta

Succin Digital
Onicofagia
Mamadera
Chupete
Succin de Labio
Succin de Objetos:

ENFERMEDADES IMPORTANTES: _______________________________________

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ACCIDENTES: _________________________________________________________
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OPERACIONES, CIRUGIAS: _____________________________________________
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TRATAMIENTOS

PREVIOS

(MEDICO,

KINE,

TERAPIA,

NUTRICION,

PSICOPEDAGOGIA, ETC.): ______________________________________________

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TRATAMIENTOS ACTUALES:___________________________________________
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MEDICAMENTOS (ALERGIAS, INSULINA, DIABETES, ETC):________________
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III.-

CONDICIONES VITALES

CMO CONSIDERAN A SU HIJO, UN NIO TRANQUILO, MAS BIEN

INQUIETO, ALEGRE, UN POCO DECAIDO, RABIOSO O PACIENTE, ETC):
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IV.-

CONTEXTO SOCIOLINGSTICO

CMO INTERACCIONA CON SU ENTORNO, SU HERMANO, PAPAS,

COLEGIO, FAMILIARES?: _______________________________________________
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CUL ES LA RUTINA DE LA SEMANA Y LA DEL FIN DE SEMANA?: ______
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CUL ES SU RUTINA PARA IRSE A DORMIR?: __________________________
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V.-

DESARROLLO COMUNICATIVO:

A QU EDAD COMENZO A BALBUCEAR, PRIMEROS SONIDOS ORALES?: __

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CMO PEDA LAS COSAS, CMO SE HACIA ENTENDER?: ________________

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CUNDO LEVANTO LA CABEZA, CUNDO SE SENT, CUANDO GATE,
CUNDO EMPEZ A CAMINAR?: _______________________________________
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CUNDO

DIJO

SUS

PRIMERAS

PALABRAS,

CULES

FUERON?:

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RENDIMIENTO ESCOLAR: ______________________________________________
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VI.-

TERAPIAS PREVIAS FLGICAS:

SI: _____

NO: ______ CUNTO TIEMPO?: ____________________________

OPINION DE LOS PADRES DE LA TERAPIA: ______________________________

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VII.- HIPOTESIS DIAGNSTICA DE LOS PADRES:
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