ANAMNESIS

Fecha actual___________________________________________________________________
Nombre: ______________________________________________ Sexo: __________________
Edad: _____ a. _____ m. Fecha Nacimiento: _________________ Escolaridad: _____________
Informante: ___________________________________________________________________

ENFERMEDAD ACTUAL:
Síntomas actuales:__________________________________________________________________
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Desde cuándo: ____________________________________________________________________

Primeros tratamientos______________________________________________________________
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HISTORIA FAMILIAR

Lugar de origen____________________________________________________________________
Datos del padre__________________________________________________________________
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Datos de la madre__________________________________________________________________
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Hermanos:_______________________________________________________________________
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Parientes que sufran enfermedades_________________________________________________

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Dinámica familiar (estilo de crianza, castigos, engreimientos, etc) _______________________

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NIÑEZ:

Tipo de niña: tímida ( ) agresiva ( ) retraída ( ) juguetona ( )

Obediente ( ) rebelde ( ) caprichosa ( )

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Datos de evolución_____________________________________________________________
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Datos de desarrollo psicosomático y neurológico____________________________________

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EDUCACIÓN:

Edad en que fue al colegio, interés escolar, estudios culminados, problemas de aprendizaje, etc.
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Repitencias (veces, razón y reacciones): ____________________________________________

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Problemas relacionados a su aprendizaje, audición, visión, parálisis, etc____________________

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Antecedentes de salud psicológica: ________________________________________________

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TRABAJO
Primer trabajo__________________________________________________________
Otros trabajos___________________________________________________________
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CAMBIOS DE RESIDENCIA
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ACCIDENTES Y ENFERMEDADES
Accidentes que ha sufrido
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Enfermedades que haya padecido
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Tuvo enfermedades venéreas?______________________________________________
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VIDA SEXUAL
Menstruación___________________________________________________________
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Conocimientos sobre sexualidad____________________________________________
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Masturbación___________________________________________________________
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Primeras relaciones_______________________________________________________
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Matrimonio_____________________________________________________________
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Hijos__________________________________________________________________
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HÁBITOS E INTERESES
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ACTITUDES PARA CON LA FAMILIA
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ACTITUD FRENTE A LA ENFERMEDAD

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SUEÑOS
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Observaciones
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