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Ficha de anamnésis

Ficha de anamnésis

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07/10/2014

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Bases Teóricas de la Psicopedagogía
Código SP0701
Psicopedagogía
Prof. Maryorie Leplat Zamora
FICHA DE ANAMNESIS
I.- ANTECEDENTES DE IDENTIFICACIÓN
Nomre del !i"o#a$%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
&ec'a de !acimie!to( %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% )dad( %%%%%%%%%%%%%%%%%%%%
*irecció!( %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% Tel+fo!o. %%%%%%%%%%%%%%%%%
Ni,el de escolaridad(%%%%%%%%%%%%%%%%%%%%%%%%%%% )stalecimie!to%%%%%%%%%%%%%%%%%%
Nomre Profesor de a-la( %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
Nomre de la madre( %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% )dad( %%%%%%%%%%%%%%
Ni,el de escolaridad de la madre( %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
.c-pació! de la madre( %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
Nomre del padre( %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% )dad( %%%%%%%%%%%%%%%%%
Ni,el del escolaridad del padre( %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
.c-pació! del padre( %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
)stado Ci,il de los padres( %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
Nomre y )dades de 'erma!os(
a$ %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
$ %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
c$ %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
d$ %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
1/.0 Moti,o de Co!s-lta( %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
11.0 *iag!óstico a!terior( %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
12.0 *atos aportados por( %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
II.- DATOS DEL EMBARAZO Y PARTO
1.0 3C-4!tos emara5os 'a te!ido6%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
7.0 38a te!ido p+rdidas6 3C-4!tas6 Se"ale moti,os.
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
/.0 3&-e emara5o deseado6 %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
1.0 39-+ edad te!ía -sted al mome!to de co!ceir a s- 'i:o6%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
2.0 3&-e -! emara5o asistido6 #prolemas de fertili5ació!$ %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
;.0 3Prese!tó sí!tomas de aorto6 3*-ra!te <-e mes6 %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
7.0 3Co!s-mió =d. >lg?! medicame!to o droga d-ra!te el emara5o6

&rec-e!teme!te )spor4dicame!te No Co!s-mió
>lco'ol
Mari'-a!a
.tras drogas
Medicame!tos
Tra!<-ili5a!tes
Cigarrillo
@@ Si co!s-mió medicame!tos especificar c-al(%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
A.0 3T-,o =d. >lg-!a e!fermedad d-ra!te el emara5o6 )specifi<-e
B.0 3)l !i"o#a$ f-e de t+rmi!o o premat-ro6 %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
10.0 3&-e parto !ormal o ces4rea6 %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
11.0 3C-4!to peso y midió al !acer6 %%%%%%% cm. %%%%%%%%%%Cg.
17.0 3c-4l f-e p-!ta:e apgar6 %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
III.- ANTECEDENTES MÓRBIDOS DEL NIÑO
1.0 38a te!ido el !i"o#a$ e!fermedades sig!ificati,as6%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
7.0 38a sido operado alg-!a ,e56 3*e <-+6 3C-4!do6%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
/.0 38a s-frido accide!tes6 3*e <-e tipo6 %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
1.0 38a co!s-ltado alg-!os de +stos especialistas6 Moti,o #solicitar i!forme$

Ne-rólogo
Psi<-iatra
Psicólogo
PsicopedagogoD)d-cadora
*ifere!cial
&o!oa-diólogo
.tros #especificar$
2.0 >!tecede!tes móridos familiares. )specifi<-e #padresE 'erma!osE familiares
cerca!os$%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
VI.-ANAMNESIS ACTUAL
1.0 3Cómo y c-a!do detecta el prolema por el c-al co!s-lta6
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
7.0 38-o alg-!a sit-ació! sig!ificati,a cerca!a al mome!to de la aparició! de los sí!tomas6
)specificar%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
/.0)F4me!es reali5ados #si es posile ad:-!tar fotocopias$%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
1.0 Tratamie!tos reali5ados y camios perciidos %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
2.0 Tratamie!to act-al%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
;.0 )specifi<-e los medicame!tos <-e esta co!s-mie!do o 'alla co!s-mido s- 'i:o#a$
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
V.-ESTRUCTURA FAMILIAR
1.0 3Co! <-ie! ,i,e el !i"o6 %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
7.0 *escria relació! eFiste!te e!tre s- 'i:o#a$ y 'erma!os#as$%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
/.0 39-i+! pasa mayor tiempo co! +l6%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
1.0 3Logra s- 'i:o c-mplir co! ciertas !ormas y tareas de la casa6
*escria%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
VI.- ANTECEDENTES DEL DESARROLLO
1.0 3T-,o lacta!cia mater!a6 *-ració!%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
7.0 3> edad come!5ó a6 Gatear%%%%%%%%%%%%% Cami!ar%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
/.0 3> edad co!trolo esfí!teres di-r!o y !oct-r!o6 %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
1.0 3Se a"a sólo o lo a"a!6 %%%%%%%%%%%%%%%%% 3Se ,iste sólo6%%%%%%%%%%%%%%%%%%%%%%%%%%
2.0 3Cómo sólo6 %%%%%%%%%% 3Tie!e dific-ltad para alime!tarse6%%%%%%%%%%%%%%%%%%%%%%%%%%%
;.0 3Cómo d-erme6 3Necesita de algo o de alg-ie!6 %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
7.0 3Prese!ta s- 'i:o#a$ pataletas o raietas a!te c-al<-ier camio impredecile6 Como
reaccio!a la familia.%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
A.0 3Prese!ta s- 'i:o#a$ alg?! medio o foia especial 'acia algo o alg-ie!6%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
B.0 3&-e o ,a al :ardí! i!fa!til6 3Le costó ir6 %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
10.0 39-i+! lo lle,a y recoge de la esc-ela6 %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
11.0 38a te!ido camios colegio o 'a perma!ecido siempre e! el mismo6
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
17. 38a repetido de c-rso6
1/. 3Cómo se lle,a co! s- profesora o profesore de a-la6
VII.- RELACIONES INPERPERSONALES
1.0 )! el primer a"o de ,ida del !i"o(
a) reaccio!aa a!te la ,o5 y rostro de la madre o c-idador%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
b) Mostraa alg?! tipo de reacció! fre!te a los eFtra"os%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
c) )stalece co!tacto ,is-al %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
d) Hec'a5a el co!tacto físico%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
7.0 >ct-alme!te el !i"o
a$ Se relacio!a adec-adame!te co! otros !i"os%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
$ Se m-estra i!difere!te fre!te a las emocio!es de los dem4s%%%%%%%%%%%%%%%%%%%%%%%%%%%
c$ I-ega co! otros !i"os%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
e) Heaccio!a i!adec-adame!te fre!te a los so!idos%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
f$ Tie!e !oció! del peligro%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
IX.- LENGUAJE Y COMUNICACIÓN
1.0 3Posee el !i"o le!g-a:e( palarasE frases6%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
7.0 3> edad come!5ó a 'alar6 %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
/.0 3Prese!ta s- 'i:o#a$ alg?! tipo de 'ailidad especial <-e le llame a =d. la ate!ció!6
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
1.0 3Le agrada a s- 'i:o la m?sica - otra acti,idad artística6%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
2.0 3S- 'i:o#a$ se com-!ica o eFpresa s- cari"o6 *e <-e formaE co! <-ie!es y co! <-e
frec-e!cia. %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
;.0 *escria e! c-atro palaras a s- 'i:o(
a$
$
c$
d$
7.0 38ay algo importa!te <-e co!sidere <-e deo saer sore s- 'i:o#a$6

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