ANAMNESIS

I. DATOS GENERALES
. Nombres y apellidos :…………………………………………………………………..
. Edad :…………………………………………………………………..
. Sexo : F M
. Fecha de nacimiento :…………………………………………………………………..
. Lugar de nacimiento :…………………………………………………………………..
. Número de hermanos :…………………………………………………………………..
. Lugar entre hermanos :…………………………………………………………………..
. Domicilio :…………………………………………………………………..
. Teléfono :…………………………………………………………………..
. Grado de instrucción :…………………………………………………………………..
. Estado civil :…………………………………………………………………..
. Fecha de evaluación :…………………………………………………………………..
. Entrevistador :…………………………………………………………………..

II. MOTIVO DE CONSULTA

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III. PROBLEMA ACTUAL

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IV. HISTORIA FAMILIAR
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V. NIÑEZ
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VI. EDUCACIÓN
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VII. TRABAJO
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VIII. CAMBIOS DE RESIDENCIA

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IX. ACCIDENTES Y ENFERMEDADES
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X. VIDA SEXUAL
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XI. HÁBITOS E INTERESES

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XII. ACTITUDES PARA CON LA FAMILIA
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XIII. ACTITUDES FRENTE AL PROBLEMA
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XIV. SUEÑOS

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