ENTREVISTA TERAPIA OCUPACIONAL

ANTECEDENTES PERSONALES
Nombre completo ___________________________________________________
Edad _____________________________________________________________
Estado Civil ________________________________________________________
Ocupación _________________________________________________________
Entrevistador y fecha entrevista: ________________________________________

ANTECEDENTES FAMILIARES
Padre_____________________________________________________________
Madre ____________________________________________________________
Con quién vive______________________________________________________
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Relación con grupo familiar____________________________________________
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Relación entre los padres _____________________________________________
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Genograma

ANTECEDENTES PSICOSOCIALES
Situación socioeconómica ____________________________________________
Situación legal ______________________________________________________
Ocupación padre e ingreso ____________________________________________
Ocupación madre e ingreso____________________________________________
Ocupación familiares e ingreso _________________________________________
Factores de Riesgo VIF ( ) MI ( ) AS ( ) OH ( ) Drog ( ) Abandono ( )
Vagancia ( ) Otro ______________________
Descripción________________________________________________________
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HISTORIA CLÍNICA
Periodo de Gestación y Nacimiento
Embarazo de la madre _______________________________________________
Estado de ánimo ____________________________________________________
Actitud de la pareja __________________________________________________
Problemas en el embarazo ____________________________________________
Periodo gestación ___________________________________________________
Tipo de parto _______________________________________________________
Problemas en el nacimiento ___________________________________________
Lactancia materna __________________________________________________
Vínculo con la madre ________________________________________________
Vínculo con el padre _________________________________________________
Otro ______________________________________________________________
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Desarrollo Psicomotor
Control de la cabeza _________________________________________________
Posición sentado ____________________________________________________
Gateo ____________________________________________________________
Marcha ___________________________________________________________
Control esfínter _____________________________________________________
Otro ______________________________________________________________

Anamnesis
Dg actual__________________________________________________________
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Inicio______________________________________________________________
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Desarrollo _________________________________________________________
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Tratantes anteriores _________________________________________________
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Tratamiento actual __________________________________________________
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Fármacos (nombre, gramaje, dosis por día)
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DESEMPEÑO OCUPACIONAL

Rutina diaria
Semana___________________________________________________________
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Fines de Semana ___________________________________________________
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Roles que desempeña

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Desempeño ABVD
Higiene menor ______________________________________________________
Higiene mayor ______________________________________________________
Control esfínter _____________________________________________________
Uso del baño _______________________________________________________
Vestimenta_________________________________________________________
Comer ____________________________________________________________
Traslado___________________________________________________________
Descripción ________________________________________________________
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Desempeño AIVD
Preparación alimentos _______________________________________________
Medicación ________________________________________________________
Uso del teléfono ____________________________________________________
Cuidado de la casa __________________________________________________
Compras __________________________________________________________
Uso transporte _____________________________________________________
Manejo dinero ______________________________________________________
Descripción ________________________________________________________
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Desempeño Descanso y Sueño
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Desempeño Escolar
Curso y colegio ____________________________________________________
Historia escolar ____________________________________________________
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Rendimiento _______________________________________________________
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Conducta __________________________________________________________
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Relación con compañeros ____________________________________________
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Desempeño Juego
Tipo de juego ______________________________________________________
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Compañeros de Juego _______________________________________________
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Desempeño Ocio y Tiempo libre

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Actividades y roles de interés

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Desempeño Participación Social

Relación con grupos sociales __________________________________________
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Relación con pares __________________________________________________
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Redes de apoyo
Familia y amigos ____________________________________________________
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Instituciones________________________________________________________
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Mapa de red / Ecomapa

Dificultades el desempeño ocupacional

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Expectativas de Intervención
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IMPRESIÓN GENERAL
Conducta manifestada _______________________________________________
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Contacto visual _____________________________________________________
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Tipo de comunicación ________________________________________________
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Conexión con la realidad _____________________________________________
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Postura corporal ____________________________________________________
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Arreglo personal ____________________________________________________
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Comentarios
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Impresión Diagnóstica
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