Documentos de Académico
Documentos de Profesional
Documentos de Cultura
Fechas de
aplicacin:
I.
IDENTIFICACIN:
Nombre Completo:
____________________________________________________________________
Fecha de nacimiento: ___________________________________ Edad:
_________________________
II. MOTIVO DE CONSULTA:
Motivo de consulta del joven:
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________________________________________________________________________________
_______________________
________________________________________________________________________________
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_____________
De la familia:
________________________________________________________________________
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_____________
IV. ANAMNESIS:
a) Antecedentes Prenatales:
Nmero de embarazos:
_________________________________________________________________
Dificultades para concebir:
_______________________________________________________________
Planificacin del embarazo:
______________________________________________________________
Respuesta emocional frente embarazo:
______________________________________________________
________________________________________________________________________________
_____
Deseos, intentos y/o abortos:
_____________________________________________________________
________________________________________________________________________________
_____
b) Antecedentes Perinatales:
Normal
Anormal
Controles de
embarazo
Si
No
ARO
Si
No
Embarazo
Observaciones
Sntomas de
prdida
Si
No
Ecografas
Si
No
Consumo
Medicamentos
en gestacin
Si
No
Parto
Vaginal
Cesrea
Peso:
Apgar
Si
No
Valor:
Compaa
Si
No
Quin?:
Patologa
perinatal
Si
No
Cul?:
kg.
Talla:
cm.
/10
c) Antecedentes Postnatales:
Diagnstico Depresin Post Parto
Si
No
Controles Peditricos
Si
No
Vacunas
Si
No
Si
Lactancia
No
1/3 meses ----- 4/6 meses ----- 7/12 meses ----- 13/18meses ----- 19/24meses ----- Ms de 2
aos -----
Alimentacin
Normal
Si
Anormal
No
________________________________________________________________________________
_____
Periodo de denticin:
___________________________________________________________________
________________________________________________________________________________
_____
Sueo
Normal
Anormal
Alteraciones:
__________________________________________________________________________
Desarrollo
Psicomotor
Normal
Anormal
Rabietas
Si
No
Estimulacin:
_________________________________________________________________________
Desarrollo del
Lenguaje
Normal
Anormal
Estimulacin:
_________________________________________________________________________
Control de
Esfnter
Normal
Anormal
Entrenamiento:
________________________________________________________________________
Recadas:
_____________________________________________________________________________
PATRN DE APEGO:
______________________________________________________________________
________________________________________________________________________________
__________
________________________________________________________________________________
__________
Antecedentes del Desarrollo Psicosexual:
Desarrollo sexual primario y secundario: ___________________________________________________
________________________________________________________________________________
_____
Conductas Inadecuadas:
________________________________________________________________
________________________________________________________________________________
_____
Actitud familia: _______________________________________________________________________
________________________________________________________________________________
_____
Impacto contexto habitacional: ______________________________________________________
________________________________________________________________________________
_____
Antecedentes Escolares:
Edad
Ingreso
a Jardn
Edad
Ingreso
a Kinder
Edad
Ingreso
a Colegio
Repitencias
Si
No
Cambios de
establecimiento
Si
No
Desercin
Escolar
Si
No
Educacin No
Formal
No
Trastorno de
Aprendizaje
Si
No
Antecedentes
Mrbidos
(Hospitalizaciones,
cadas, golpes,
accidentes y
enfermedades)
Si
No
EDA
D
LUGAR
MOTIVO
DURACIN
FINALIZ
A
Psicologa
Neurolog
a
Psiquiatr
a
Nutricioni
sta
Otro
DURACIN
FINALIZA
APS
PAI
PR
(CT ---)
UHCE
PAC
OTRO
SI
DEPRODE
NO
FECHA
INTITUCIN
DEDEREJ
VIII.
MEDIDA
MEDIO
LIBRE
PSA
MCA
SBC
PLA
PLE
CSC
-------------------------
MEDIDA
PRIVATIVA
DE
LIBERTAD
GENCHI
COD
CERECO
CIP
CRC
------------------------
ANTECEDENTES DE VULNERACIONES:
Si
Problemas econmicos.
Problemas habitacionales.
Problemas de acceso a servicios de salud y otros servicios.
Negligencia parental
Abandono parental
Maltrato fsico
Maltrato psicolgico
Abuso sexual
Violencia Intrafamiliar
Peores formas de trabajo infantil
Explotacin sexual, comercial infantil
IX.
OBSERVACIN CLNICA
No
rea Intelectual
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rea Emocional
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Contexto Sociocultural e Infraccin de ley
________________________________________________________________________________
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X.
ANTECEDENTES FAMILIARES
________________________________________________________________________________
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Fecha
Profesional Responsable
Firma