ANAMNESIS

I. DATOS GENERALES.

Nombres y Apellidos                    : __________________________________

Lugar y Fecha de Nacimiento       : _________________________________

Edad Actual                                 : __________________________________

Sexo                                            : __________________________________

Estado Civil                                 : __________________________________

Dirección                                     : __________________________________

Ocupación                                   : __________________________________

Religión                                      : ___________________________________

Informante                                  : ___________________________________

Referente                                   : ___________________________________

Fechas de Estudio                     : ____________________________________

Lugar de la Consulta                   : ___________________________________

Motivo de la Consulta                 : ____________________________________

Examinador                                : ____________________________________

II. PROBLEMA ACTUAL

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III. HISTORIA PERSONAL.

a. Gestación. 

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b. Nacimiento

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c. Niñez.

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d. Escolaridad

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e. Pubertad y Adolescencia.

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IV. HISTORIA FAMILIAR.

Padre:

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Madre

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Hermanos:

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V. HISTORIA SOCIO – ECONÓMICA.

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