ANAMNSIS

FECHA: ___________________ DATOS OTORGADOS POR: _________________________________

ENTREVISTADOR: _________________________________________________________________

A) DATOS DE IDENTIFICACIN

NOMBRE: _______________________________________________________________________

FECHA DE NACIMIENTO: _________________ EDAD: ______________ SEXO: _________________

DIRECCIN: ________________________________________ TELFONO: ___________________

CON QUIEN VIVE EL MENOR: ________________________________________________________

B) ANTECEDENTES ESCOLARES

ESCOLARIDAD, ESTABLECIMIENTO Y CURSO:

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ASISTE REGULARMENTE
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RENDIMIENTO ESCOLAR
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C) ANTECEDENTES DEL EMBARAZO

HISTORIA PRENATAL (Programacin de embarazo, edad gestacional, antecedentes mrbidos

durante el embarazo, eclampsia, diabetes gestacional, etc):
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CONTROL MDICO (Consumo de medicamentos durante el embarazo, drogas)

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TRASTORNOS EMOCIONALES Y ESTADO EMOCIONAL DE LA MADRE EN EMBARAZO (ansiedad,

depresin, trastornos alimenticios de la madre, etc. Soluciones en caso de trastorno):
________________________________________________________________________________
________________________________________________________________________________
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FACULTAD DE CIENCIAS DE LA SALUD ESCUELA DE FONOAUDIOLOGA

Internado Nios Fundacin San Nectario
HISTORIA PERINATAL (Parto, frcep, inducido, meses de gestacin, peso, talla, apgar, asfixia,
convulsiones, parlisis, hemorragias, traumatismos, ictericia, lactancia materna, tipo de
alimentacin):
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ANTECEDENTES MRBIDOS (Asfixia, convulsiones, hemorragias, parlisis, traumatismos, ictericia):

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HISTORIA POSTNATAL (antecedentes mrbidos significativos; epilepsia, encefalitis, meningitis,

toxoplasmosis, afecciones cardiovasculares, trastornos visuales, auditivos).
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ALERGIAS, CONSUMO DE MEDICAMENTOS, CULES Y POR QUE

________________________________________________________________________________
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D) ANTECEDENTES SIGNIFICATIVOS EN REAS DEL DESARROLLO

DESARROLLO PSICOMOTOR (edad en que fij la cabeza, se sent, gate, camin, control de
esfnter (nocturno-diurno)).
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ACTIVIDAD MOTORA (Activo, hipo activo, estereotipias):

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LENGUAJE (Balbuceo, edad de as primeras palabras, palabra-frases, lenguaje contextualizado):

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HBITOS DE SUEO Y VIGILIA / HBITOS ALIMENTICIOS (Horarios, tipos de comida, textura,

trastornos alimenticios:
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________________________________________________________________________________
________________________________________________________________________________

FACULTAD DE CIENCIAS DE LA SALUD ESCUELA DE FONOAUDIOLOGA

Internado Nios Fundacin San Nectario
 E) EMOCIONAL SOCIAL

DEMOSTRACIN ANMICA (Adecuado, tolerancia a la frustracin, fantasas excesivas, tmido,

obsesivo, agresiones, mitomana, meticuloso, disruptivo, etc) / DEMUESTRA SUS EMOCIONES Y
CMO:
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OBEDECE FCILMENTE / CUIDA Y ORDENA SUS COSAS

________________________________________________________________________________
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COMPARTE CON LOS DEMS SUS INICIATIVAS:

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F) HISTORIA FAMILIAR

NOMBRE DE LA MADRE____________________________________________________________
EDAD:______ OCUPACIN : _________________________________________________________
NOMBRE DEL PADRE: ______________________________________________________________
EDAD:______ OCUPACIN: _________________________________________________________
HERMANOS: Si____ No____ (En caso de s, agregar nombre, edad, sexo, lugar que ocupa,
ocupacin)
________________________________________________________________________________
________________________________________________________________________________

ANTECEDENTES MRBIDOS:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

EXMENES MDICOS (Neurolgicos, psicolgicos, etc):

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DIAGNSTICOS (FECHAS):
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________________________________________________________________________________
________________________________________________________________________________

FACULTAD DE CIENCIAS DE LA SALUD ESCUELA DE FONOAUDIOLOGA

Internado Nios Fundacin San Nectario
TRATAMIENTOS:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

ANTECEDENTES MORBIDOS DEL NIO:

EXMENES MDICOS (Neurolgicos, psicolgicos, etc):

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DIAGNSTICOS (Profesional que diagnstica y fecha):

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TRATAMIENTO MEDICAMENTOSO:
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TRATAMIENTO DE PROFESIONALES NO MDICOS (Dnde, por cuanto tiempo, por qu

profesionales):
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________________________________________________________________________________
________________________________________________________________________________

__________________________

FIRMA EVALUADOR

FACULTAD DE CIENCIAS DE LA SALUD ESCUELA DE FONOAUDIOLOGA

Internado Nios Fundacin San Nectario