FICHA DE RECEPCIN INFANTIL

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1. Identificacin:

NOMBRE:___________________________________________________
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FECHA DE
NACIMIENTO:_______________________________________

EDAD:______________________________________________________
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ESCOLARIDAD:_____________________________________________
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ESTAB.
EDUCACIONAL:_________________________________________

DIRECCIN:________________________________________________
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2. MOTIVO DE CONSULTA:
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3. SINTOMATOLOGA PRESENTADA:
Caractersticas Conductuales: ________________________________________
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Caractersticas emocionales: _________________________________________
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Caractersticas orgnicas: ___________________________________________
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4. ANTECEDENTES FAMILIARES:

Genograma:

Dificultades ambientales: (si) (no) ___________________________________

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Dificultades de Pareja: (si) (no) _____________________________________
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Antecedentes de problemas psiquitricos de padres o hermanos: (si) (no)
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5. ANTECEDENTES ACADMICOS:

Repitencia: (si) (no) _______________________________________________

Dificultades de aprendizaje: (si) (no) ________________________________
Dificultades con el profesor: (si) (no) ________________________________
Dificultades de adaptacin escolar: (si) (no)
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Dificultades para relacionarse con pares: (si) (no) _____________________
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Otros:
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6. ANTECEDENTES SOCIALES:

Problema de integracin a pares: (si) (no)

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Actitud pasiva: (si) (no) _____________________________________________
Actitud agresiva: (si) (no) ___________________________________________
Otros: _____________________________________________________________
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7. CONSULTAS O TRATAMIENTOS PREVIOS:

Psicologa: (si) (no) ________________________________________________

Psicopedagoga: (si) (no) ____________________________________________
Neurologa: (si) (no) ________________________________________________
Psiquiatra: (si) (no) ________________________________________________

8. CARACTERSTICAS ESPECIALES:

Talla baja o excesivamente alta: (si) (no)

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Pesos superiores o inferior anormal: (si) (no) ___________________________
Facia especial: (si) (no) _____________________________________________
Rasgos exagerados: (si) (no) _________________________________________
Cicatrices visibles: (si) (no) __________________________________________
Tics: (si) (no) ______________________________________________________
Malformaciones congnitas: (si) (no) __________________________________
9. IMPRESIN CLNICA Y DIAGNSTICO PRELIMINAR:
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