HISTORIA CLÍNICA INFANTIL

I.DATOS PERSONALES

Nombre: __________________________________________________________________
Numero de Ficha: ___________________________ Edad: __________________________
Nombre del Terapéutica: ____________________________________________________

II. MOTIVO DE CONSULTA (Descripción del problema, frecuencia, duración, etc.)

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III. GRUPO FAMILIAR

NOMBRE RELACION EDAD ESCOLARIDAD ACTIVIDAD

IV. GENOGRAMA

V. DESCRIPCIÓN DE LA DINAMICA FAMILIAR

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VI. ANTECEDENTES PERSONALES

 Antecedentes Obstétricos y de Recién Nacido:

Embarazo (duración, enfermedades, clima psicológico, etc.)

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Parto:
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Recién Nacido (Peso, talla características especiales, etc.):

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 Antecedentes de Desarrollo
Crecimiento y desarrollo (Lactancia, desnutrición, etc.):
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Desarrollo Psicomotor: ______________________________________________________
Sujeta la Cabeza: ___________________________________________________________
Se para solo: _______________________________________________________________
Gatea: ____________________________________________________________________
Marcha: __________________________________________________________________
Lenguaje: _________________________________________________________________
Primeras Palabras: __________________________________________________________
Control de Esfínter: _________________________________________________________
 Antecedentes Escolares:
Jardín Infantil (Adaptación, conducta, etc.)
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 Pre- Kínder y Kínder:
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Primero Básico (dificultades, aprendizaje, lecto-escritura, aprendizaje matemáticas, etc.):
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Escolaridad Actual:
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 Antecedentes Sociales:
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VII. ANTECEDENTES FAMILIARES:
Madre (Nombre, edad, ocupación, relación con el niño(a), etc.)
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Padre (Nombre, edad, ocupación, relación con el niño (a), etc.)

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 Hermanos (Nombre, describirlos de acuerdo a la edad, a la escolaridad, etc.):
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Personas con que el niño tiene mejor relación:

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Tipo de afiliación con los padres (matrimonios, separados, etc.):
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Personas con quien vive el niño en la casa:
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Antecedentes Psiquiátricos
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Otros antecedentes:
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VIII. DIAGNÓSTICO:
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IX. PLAN DE TRATAMIENTO:

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