EXAMEN MENTAL

I. DATOS DE FILIACIN
1. 1 Apellidos y Nombres
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1.2 Edad: __________________________ 1.3 Sexo:
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1.4 N de Hermanos: __________________ 1.5 Lugar entre
Hermanos
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1.6 Fecha de Nac.: ___________________ 1.7 Lugar de Nac.
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1.8 Ocupacin: ______________________ 1.9 Grado de Instruccin
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1.10 Fecha de Evaluacin: _____________________________
II. ASPECTO GENERAL
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III.

COMPORTAMIENTO DURANTE LA ENTREVISTA

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IV.CONCIENCIA
Obnubilacin
Confusin

( )

( )

V. ORIENTACIN
De tiempo

Somnolencia
Lucidez

( )

( )

Oniroide ( )

Presente

( )

Incompleta ( ) Ausente ( )

Presente

( )

Incompleta ( ) Ausente ( )

Presente

( )

Incompleta ( ) Ausente ( )

De espacio
De-persona

VI.

ATENCIN

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VII. MOTRICIDAD
Actividad motora general
Normal (

Hipoactividad (

Hiperactividad (

Actividad motora postural

Normal ( )
Hipertnica

Hipotnica
(

( )

Manipulacin de objetos
Normal ( )

Torpe ( )

Muy torpe

Torpe ( )

Muy torpe

)
Actividad motora fi na
Normal ( )
)
Alteraciones motoras
No tiene

LEVE

MODERADO

SEVERO

VIII.

1.

Tics

II.

Temblores

III. Estereotipos (

PERCEPCIN

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IX. AFECTIVIDAD Y EMOCIONES
Humor_________________________________________________________
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Afecto__________________________________________________________
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_Adecuacin____________________________________________________
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X.

PENSAMIENTO
Curso__________________________________________________________
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Contenido______________________________________________________
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Nivel de pensamiento: Concreto (

Abstracto (

Funcional (

XI. LENGUAJE
Grado de desarrollo del lenguaje hablado
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Grado de desarrollo de escritura
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Grado de desarrollo de lectura

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Alteraciones de la lectura y escritura
Escritura________________________________________________________
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Lectura__________________________________________________________
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XII. MEMORIA
A largo plazo

Presente ( )

Incompleta ( )

Presente ( )

Incompleta ( )

Ausente ( )
A corto plazo
Ausente ( )
De fijacin

Presente (

Incompleta ( )

Ausente ( )
XIII.

JUICIO

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XIV.INSIGHT
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XV. CONTROL DE IMPULSOS
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XVI.

INTELIGENCIA

Inferior al Promedio

( )

Normal Promedio

( )
Superior al Promedio

( )

XVII. FIABILIDAD_________________________________________________
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