PROTOCOLO DE ENTREVISTA EVALUACIÓN NEUROPSICOLÓGICA

FECHA: ________________________________ EVALUADOR: _____________________________________________

NOMBRE: ___________________________ CC: ___________________ FECHA NACIMIENTO: ______________________

EDAD: __________________ OCUPACIÓN: _____________________________ LATERALIDAD: ______________________

ESCOLARIDAD: ___________________________________________ EPS: ______________________________________

INFORMANTE: __________________________________________ PARENTESCO: ________________________________

TELÉFONO INFORMANTE: ____________________________ TELEFONO PACIENTE: ______________________________

HISTORIA CLÍNICA: (Primera Consulta Psiquiatría o Neurología. Curso de los Síntomas. Embarazo. Desarrollo Normal.
Colegio. Relaciones Familiares y con Otros. Actualidad. Traumas Craneales. Convulsiones. Sincopes. Otras Enfermedades.
Tóxicos o Alérgicos. Quirúrgicos. Antecedentes Familiares.)

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

ANÁLISIS DE LA CONDUCTA:

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

PLAN FARMACOLÓGICO:

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

EXÁMENES COMPLEMENTARIOS:

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

IMPRESIÓN DIAGNÓSTICA:

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________