ACTA DE VISITA DOMICILIARIA

1. INFORMACIÓN GENERAL

Fecha de la visita:_______________________ Fecha elaboración del informe:

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Datos del profesional que realiza la visita:

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2. DATOS BÁSICOS DEL SUJETO.

NOMBRES Y APELLIDOS:

SEXO: FECHA DE NACIMIENTO EDAD

DIRECCION TELEFONO N IDENTIFICACION

3. DATOS DE LA PERSONA QUE ATIENDE LA VISITA

Nombres y apellidos: _________________________________________________________

Tipo y número de documento de identidad: _____________________________________

Fecha de Nacimiento: __________________________________ Edad:________________

Dirección de residencia:_______________________________________________________

Barrio:___________________________________Teléfono:__________________________

Parentesco: ________________________________________________________________

OBJETIVO:______________________________________________________________
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COMPOSICIÓN FAMILIAR ACTUAL

n Nombres y Apellidos Parentesco Edad Escolaridad

Estado Activida Ocupació
Civil d n
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CONDICIONES HABITACIONALES Y ASPECTOS SOCIO ECONOMICOS

Tenencia de la Propia Familiar Arrendada Otra.

vivienda ¿Cuál?
Zona de invasión Si No Estrato
Urbana Rural Tiempo de permanencia
Ubicación
en la vivienda:
Acueducto y Energía Manejo de basuras
Equipamiento de alcantarillado
Servicios públicos Gas domiciliario

Número de Número de residentes Otros espacios

Distribución de habitaciones en el mismo techo
Espacios

Descripción de la
vivienda y Riesgos
estructurales

Apropiación de
recursos
económicos:
Ingreso y
distribución.

Observaciones
Adicionales

GENOGRAMA

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DESARROLLO:

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ACTUACIONES:
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RECOMENDACIONES:
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COMPROMISOS:
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FIRMAS

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USUARIO ACOMPAÑANTE

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PROFESIONAL PSICOSOCIAL PROFESIONAL EN SALUD
QUE REALIZA LA VISITA QUE REALIZA LA VISITA

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COORDINADOR(A) GA

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