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A N A M N E S I S

Fecha actual___________________________________________________________________

Nombre: ______________________________________________ Sexo: __________________Edad: _____ a. _____ m. Fecha Nacimiento: _________________ Escolaridad: _____________

Informante: ___________________________________________________________________

ENFERMEDAD AC!A":

S#ntomas actuales:__________________________________________________________________

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Desde cu$ndo: ____________________________________________________________________

%rimeros tratamientos______________________________________________________________

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HISTORIA FAMILIAR

"u&ar de ori&en____________________________________________________________________

Datos del 'adre__________________________________________________________________

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Datos de la madre__________________________________________________________________

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(ermanos:_______________________________________________________________________

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%arientes )ue sufran enfermedades_________________________________________________

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Din$mica familiar *estilo de crian+a, casti&os, en&reimientos, etc- _______________________

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NIEZ:

i'o de nia: t#mida * - a&resi/a * - retra#da * - 0u&uetona * -

1bediente * - rebelde * - ca'richosa * -

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Datos de e/oluci2n_____________________________________________________________

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Datos de desarrollo 'sicosom$tico 3 neurol2&ico____________________________________

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EDUCACIN:

Edad en )ue fue al cole&io, inter4s escolar, estudios culminados, 'roblemas de a'rendi+a0e, etc.

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Re'itencias */eces, ra+2n 3 reacciones-: ____________________________________________

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%roblemas relacionados a su a'rendi+a0e, audici2n, /isi2n, 'ar$lisis, etc____________________

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Antecedentes de salud 'sicol2&ica: ________________________________________________

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TRABAJO

%rimer traba0o__________________________________________________________

1tros traba0os___________________________________________________________

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CAMBIOS DE RESIDENCIA

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ACCIDENTES Y ENFERMEDADES

Accidentes )ue ha sufrido

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Enfermedades )ue ha3a 'adecido

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u/o enfermedades /en4reas5______________________________________________

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VIDA SEXUAL

Menstruaci2n___________________________________________________________

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Conocimientos sobre sexualidad____________________________________________

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Masturbaci2n___________________________________________________________

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%rimeras relaciones_______________________________________________________

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Matrimonio_____________________________________________________________

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(i0os__________________________________________________________________

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HBITOS E INTERESES

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ACTITUDES PARA CON LA FAMILIA

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ACTITUD FRENTE A LA ENFERMEDAD

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SUEOS

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Obser!"#$%es

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