ALCALDIA DE MANAGUA

DIRECCION MUJER Y FAMILIA

VISITA DE AMOR Y SOLIDARIDAD A MADRES/PADRES DE HEROES Y MARTIRES.

FECHA: __________________
I. DATOS GENERALES MADRE/PADRE.
NOMBRES Y APELLIDOS:____________________________________________________________
EDAD: ____NÚMERO CEDULA__________________FECHA DE NACIMIENTO: __________________
DIRECCION ACTUAL: ______________________________________________________________
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II. DATOS DEL CAIDO.
NOMBRE DEL HIJO CAIDO: _________________________________________________________
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FECHA Y LUGAR DONDE CAE EL COMPAÑERO: __________________________________________
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BREVE RESEÑA HISTORICA DEL CAIDO:_______________________________________________
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DONDE SE ENCUENTRAS SUS RESTOS ACTUALMENTE: ____________________________________
III. SITUACION SOCIAL-ECONOMICA Y FAMILIAR.
SITUACION SOCIO-ECONOMICA (EXPLICAR O DESARROLLAR LOS TIPOS DE PENSION/AYUDAS
ECONOMICAS): ____________________________________________________________________
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ESTADO DE LA VIVIENDA: __________________________________________________________
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SITUACION FAMILIAR: _____________________________________________________________
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IV. EXPLORACIÓN PSICOPATOLÓGICA GENERAL
ACTITUD GENERAL AL INICIO DE LA ENTREVISTA:_____________________________________
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ASPECTO FÍSICO Y POSTURA CORPORAL: ______________________________________________
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ESTADO DE SALUD (HISTORIAL DE SALUD): __________________________________________
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SÍNTOMAS DE DETERIORO PSÍQUICO EN ELLA/EL(SI/NO)ESPECIFIQUE:_____________________
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CONCIENCIA:______________________________________________________________________
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ORIENTACION:_____________________________________________________________________
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ATENCION:________________________________________________________________________
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NIVEL DE PSICOMOTRICIDAD:________________________________________________________
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SENSORIO PERCEPCION (CONTENIDO Y PROCESOS DEL PENSAMIENTO):______________________
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MEMORIA:_________________________________________________________________________
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LENGUAJE:________________________________________________________________________
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AFECTIVIDAD:_____________________________________________________________________
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JUICIO:__________________________________________________________________________
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ASPECTOS MOTORES DEL COMPORTAMIENTO Y LA CONDUCTA DURANTE LA ENTREVISTA:
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LA INTELIGENCIA:_________________________________________________________________
V. OBSERVACIONES Y NECESIDADES ENCONTRADAS
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VI.IMPRESION DIAGNOSTICA.
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VII. RECOMENDACIONES

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ATENDIDO POR: _____________________________

ORIENTADOR PSICOSOCIAL.