FORMATO DE VISITA DOMICILIARIA

FECHA DE REALIZACIÓN ____/____/____/

DATOS PERSONALES

INFORMACIÓN DEL BENEFICIARIO

TIPO DE BENEFICIARIO MADRE GESTANTE NIÑO   NIÑA  
DATOS DEL BENEFICIARIO
NOMBRES  
APELLIDOS   
NÚMERO DE DOCUMENTO DE
IDENTIDAD  
FECHA DE EXPEDICIÓN  
LUGAR DE EXPEDICIÓN  
FECHA DE
DEPARTAMENTO   NACIMIENTO      
EDAD AÑOS SEXO F M  
 
PAIS DE NACIMIENTO  
DEPARTAMENTO DE   
NACIMIENTO  
 
MUNICIPIO DE NACIMIENTO  

MOTIVO DE LA VISITA

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No NOMBRES APELLIDOS EDAD PARENTESCO
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DATOS FAMILIARES
 No de habitaciones: No de baños:

Acabado de la vivienda:
CONDICIONES DE LA VIVIENDA
TERMINADA A MEDIO TERMINAR OBRA NEGRA

Condiciones de higiene:

ADECUADO REGULAR DEFICIENTE

Servicios:

Agua Aseo Electricidad Gas alcantarillado Telefonía Tv Cable

Observaciones del entrevistador:

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ASPECTOS RELACIONALES
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ASPECTOS FAMILIARES
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Normas Familiares:
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Adaptabilidad:
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ESTRATO:
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Cohesión:
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NÚMERO DE PERSONAS A CARGO:
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Figuras de autoridad:
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Ingresos económicos:
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Nombres Apellidos En que labora Ingresos mensuales
Redes de Apoyo:
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Calidad de las Relaciones Familiares:

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Gastos mensuales:
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ANTECEDENTES MÉDICOS
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Ha sido intervenido (a) quirúrgicamente: NO SI

Razones (en caso de que la respuesta sea SI): GENOGRAMA

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Consume algún fármaco prescrito medicamente: NO SI

Razones (en caso de que la respuesta sea SI):

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Ha desarrollado tratamiento psicológico o psiquiátrico:

NO SI
Razones (en caso de que la respuesta sea SI):
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CONDICIÓN SOCIOECONÓMICA
Conclusiones del profesional :
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Compromisos:
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SEGUIMIENTO VISITA DOMICILIARIA
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Fecha Visita anterior: ____________________________ Fecha Visita actual: ____________________________
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Nombre del Beneficiario: ________________________________________________________________________
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UDS: _________________________________________ EAS: ___________________________________________
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Evolutivo:
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Firma Profesional Firma Padre, madre y/o cuidador
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Fecha de próxima visita: ___________________________________________________________________________
Firma Profesional: ________________________________________________________________________________
Firma Padre, madre y/o cuidador: ___________________________________________________________________