Documentos de Académico
Documentos de Profesional
Documentos de Cultura
I. DATOS DE FILIACIÓN:
Nombre :....................................................................................................
Edad :....................................................................................................
Sexo :....................................................................................................
Teléfono :....................................................................................................
Entrevistador :....................................................................................................
II.DESCRIPCIÓN DE LA CONDUCTA:
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
IV. MOTIVO DE CONSULTA (frecuencia, duración, intensidad)
¿Qué Le Pasa?
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
FAMILIA
PAREJA
AMISTADES
ESCUELA
TRABAJO
SALUD FÍSICA
V. ESTRUCTURA FAMILIAR:
Características generales de las personas que viven en la casa, con especial atención a los padres,
hermanos (edad, profesión, carácter, enfermedades, defunciones, abortos, diversiones, etc), abuelos
y parientes próximos.
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
DESARROLLO PRENATAL
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
ALIMENTACIÓN
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
DESARROLLO MOTOR
¿Características del mantenimiento de la cabeza erguida, sentado sin apoyo, gateo, sostenerse
en pie, iniciación de la marcha?
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
LENGUAJE
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
HÁBITOS HIGIÉNICOS
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
Atento () Distraído ()
Accesible () Terco ()
Obediente () Desobediente ( )
Tranquilo () Inquieto ()
Deprimido () Alegre ()
Comunicativo ( ) Parco ()
Sociable () Reservado ()
Agresivo () No agresivo ( )
Trastornos en el sueño:
Somniloquia () Sonambulismo ()
ENFERMEDADES
¿Antecedentes familiares?
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
SÍNTOMAS PSICONEURÓTICOS
Onicofagia () Bruxismo ()
Coprofagia () Enuresis ()
Encopresis () Pica ()
Bulimia () Anorexia ()
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
¿Especial atención a deportes y/o lectura?
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
¿Usted consume algún tipo de licor, fuma o se droga? ¿Qué piensa de los que lo hacen?
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
X. AMBIENTE ESCOLAR
¿Nido?.................................................................................¿Edad?:......................................
................................................................................................................................................................
...............................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
¿Qué le gusto?
................................................................................................................................................................
................................................................................................................................................................
¿Escuela?.............................................................................¿Edad?....................................
................................................................................................................................................................
................................................................................................................................................................
¿Qué dificultades tuvo? (Si repitió algún grado o tuvo problema con alguien o algún curso)
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
...............................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
¿Qué le gusto?
................................................................................................................................................................
................................................................................................................................................................
¿Era sociable?
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
¿Colegio?.............................................................................¿Edad?....................................
................................................................................................................................................................
................................................................................................................................................................
¿Qué dificultades tuvo? (Si repitió algún grado o tuvo problema con alguien o algún curso)
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
...............................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
¿Era sociable?
................................................................................................................................................................
................................................................................................................................................................
¿Qué cambios hubo en usted? ¿y a qué edad?
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
...............................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
...............................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
...............................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
...............................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
...............................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
...............................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
...............................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
XII. RECOMENDACIONES
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
...............................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
.........................................
Entrevistador