INSTITUTO ESCOLAR GENERACIN 2000EL CONOCIMIENTO ES LA LIBERTAD DEL HOMBREHISTORIA CLNICA1. DATOS GENERALESDATOS DEL MENOR:NOMBRE: ____________________________________________________________EDAD: ___________FECHA DE NACIMIENTO: _________________________ SEXO: _______DOMICILIO: ________________________________________________________________TELFONO PARTICULAR: _________________________DATOS FAMILIARES:NOMBRE DEL PADRE: __________________________________EDAD:__________ESCOLARIDAD: __________________________RELIGIN:_______________OCUPACIN: _______________________________NOMBRE DE LA MADRE: ______________________________________EDAD:__________ESCOLARIDAD: __________________________RELIGIN:_______________OCUPACIN: _______________________________HISTORIA FAMILIAR:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________FAMILIOGRAMA:DESCRIPCIN DEL PROBLEMA QUE EL MENOR PRESENTA ACTUALMENTE:______________________________________________________________________________________________________________________________________________________________________________________________________________________________CULES FUERON LAS CONDICIONES DEL EMBARAO ! LAS REACCIONES DEL PADRE ! LA MADRE"_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________FUE UN EMBARAO PLANEADO"________________________________________________________________HUBO DIFICULTADES"_________________________________________________________________________MEDICAMENTOS"____________________________________________________________________________DURACIN: __________________________________________________________________________________PARTO:FUE ESPONTNEO# PRO$OCADO# CON ANESTECIA# CON CESREA:_________________________________________________________________________________________________________________________________$EN%A DE NALGAS# DE CARA# DE CABEA# CON $UELTA DE CORDN:_______________________________________________________________________________________________________________________________MANIOBRA DE FRCEPS: ______________________________________________________________________LLOR AL NACER: _____________________________________________________________________________PESO: ____________________________TALLA:_________________________CALIFICACIN: ______________________________________________________________PRIMEROS PASOS: _______________________PRIMERAS PALABRAS: ______________________CONTROL DE ESF%NTER: _____________________ENFERMEDADES PADECIDAS: __________________________________________________OPERACIONES QUIR&R'ICAS: __________________________________________________DESCRIBA CMO ES LA ALIMENTACIN DEL NI(O:)* CULES SON LOS ALIMENTOS QUE CONSUME EL MENOR:______________________________________________________________________________________________________________________________________________________________________________________________________________________________DESA!UNA: ___________________________COME: _______________________________CENA: __________________________________ENTRE HORAS: ___________________________2* EN ALGUNA ETAPA DE SU DESARROLLO HA NOTADO CAMBIOS EN SU ALEMENTACIN"# +PRDIDA DE APETITO# O AUMENTO,*_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________-* ALGUNA $E EL NI(O SE HA ACCIDENTADO O SE HA ENFERMADO"______________________________________________________________________________________________________________________________________________________________________________________________________________________.* EL MENOR:/, A QU HORA SE ACUESTA"0, CON QUIN COMPARTE LA HABITACIN"1, CON QUIN COMPARTE LA CAMA"2, CMO ES EL CICLO DEL SUE(O"COMPORTAMIENTO DEL NI(O)* DESCRIBA LA MANERA DE SER DEL NI(O RESPECTO A:SOCIALIACIN: __________________________________________________________________________AGRESI$IDAD: ____________________________________________________________________________OBEDIENCIA: _____________________________________________________________________________NI$EL DE ACTI$IDAD: ______________________________________________________________________NI$EL DE ATENCIN: _______________________________________________________________________MIEDOS:)* EL NI(O ES CONFIADO O DESCONFIADO" DE QUIN"___________________________________________________________________________________________________________________________2* A QU LE TIENE MIEDO EL NI(O"/, / 3/ 45167" _____0, / 3/ 5819:;2/2"________1, / 3/ 85372/2"__________2, / 358 39, / 3/8 ?73@193/8 27 =7::5:"_________, DE QUIN"_______________________________________EDAD:______________SEXO:____________LUGAR:______________________________________________________________________________)* EL NI(O SE LO CONT"_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________2* EN CASO DE NO SER AS%# CMO SE ENTER"_________________________________________________________________________________________________________________________________________________________-* CMO REACCION USTED"______________________________________________________________________________________________________________________________________________________________________.* CMO REACCION LA FAMILIA"__________________________________________________________________________________________________________________________________________________________________H* CMO REACCION EL NI(O"_____________________________________________________________________________________________________________________________________________________________________/, EL NI(O HA CONTADO SI LE HAN TOCADO SUS GENITALES"_______________________________________________QUIN":_______________________________EDAD:________________SEXO_______________________________CMO ! CUNDO SUCEDI"____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________LUGAR +ESPACIO F%SICO,___________________________________________________________________________0, RECIBI ATENCIN PSICOLGICA O MDICA"__________________________________________________________EN QU INSTITUCIN"___________________________________________________________________________CUNTO DUR EL TRATAMIENTO"_________________________________________________________________TERMIN SU TRATAMIENTO"______________________________________________________________________QUINES ACUDIERON A RECIBIR ATENCIN PSICOLGICA"_____________________________________________________________________________________________________________________________________________SE SIGUE PRESENTANDO ESTA CONDUCTA"___________________________________________________________MALTRATO:)* SABE USTED LO QUE ES EL MALTRATO"______________________________________________________________________________________________________________________________________________________2* SE PRESENTA MALTRATO DENTRO DE SU HOGAR" EN QU FORMA"___________________________________________________________________________________________________________________________-* CON QU FRECUENCIA SE PRESENTA"__________________________________________________________.* LOS MENORES ESTN PRESENTES DURANTE EL MALTRATO" _________________________________________CONDUCTA ! MANE'O DE LA AUTORIDAD:)* DESCRIBA CUL ES LA CONDUCTA DEL MENOR ! USTED CMO MANE'A SU AUTORIDAD:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________/, EL MENOR ARREMETE F%SICA ! $ERBALMENTE"_____________________________________________________________________________________________________________________________________________PRESENTA CONDUCTAS DE AUTODESTRUCCIN"______________________________________________________________________________________________________________________________________________CMO ES SU RELACIN CON EL PADRE"____________________________________________________________________________________________________________________________________________________CMO ES SU RELACIN CON LA MADRE"____________________________________________________________________________________________________________________________________________________DESCRIBA LA CONDUCTA DE SU HI'O+A,______________________________________________________________________________________________________________________________________________________CON QUIN 'UEGA"__________________________________________________________________________CMO CONSIDERA SU RENDIMIENTO ESCOLAR"___________________________________________________HA PASADO POR ALGUNA SITUACIN DE DUELO RECIENTEMENTE"______________________________________________________________________________________________________________________________HA RECIBIDO TRATAMIENTO PEDAGGICO O TERAPUTICO"____________________________________________________________________________________________________________________________________IMPRESIN DIAGNSTICA:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________CONCLUSION ! ACCIONES A SEGUIR:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________