HISTORIA PSICOLGICA EDUCATIVA

I. DATOS DE FILIACIN.
Nombres y apellidos
:
Edad
:
Sexo
:
Lugar y fecha de nacimiento
Grado acadmico
Lugar que ocupa en la familia
Con quines vive
Nombre, edad e instruccin del padre
Nombre, edad e instruccin de la madre
Institucin Educativa
:
Domicilio
Fechas de entrevista y evaluacin
Ps. Entrevistador

:
:
:
:
:
:
:
:
:

II. PROBLEMA ACTUAL.

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III. IMPRESIN PERSONAL U OBSERVACIN DE CONDUCTA.
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IV. IMPRESIN SOBRE EL PROBLEMA ACTUAL.
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V. HIPTESIS.
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VI.ANTECEDENTES PERSONALES Y FAMILIARES.

- Embarazo:
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-

Parto:
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Desarrollo psicomotor:
a) Examen
de
reflejos:
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b) Sentarse:
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c) Gatear:
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d) Caminar:
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e) Anomalas
al
momento
de
caminar
o
correr:
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f) Desarrollo
psicomotor
grueso:
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g) Desarrollo
psicomotor
fino:
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Desarrollo del lenguaje:

a) Sonidos
guturales:
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b) Balbuceo:
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c) Edad
en
que
comenz
a
hablar:
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d) Edad
en
que
manejaba
frases:
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e) Suele comunicarse con frecuencia: __________________________________________________
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f) Dominio de las trabadas: _____________________________________________________________
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g) Anomalas en el lenguaje: ____________________________________________________________

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Relacin
de
pareja
entre
los
padres:
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_
Relacin con los hermanos: ____________________________________________________________
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_
Relacin con el padre: ____________________________________________________________
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_
Relacin con la madre: ____________________________________________________________
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_
A
quin
prefiere
(madre
o
padre):
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_
Relacin
con
pares
(socializacin):
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Relacin con otros adultos: ____________________________________________________________
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Alimentacin:
a) Primeros
12
meses
de
vida:
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b) Primero
al
segundo
ao
de
vida:
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c) Tercero
al
quinto
ao
de
vida:
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d) De los 6 a 12 aos: ____________________________________________________________
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e) De 12 aos a 18 aos: ____________________________________________________________
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f) De 18 aos en adelante: ____________________________________________________________
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Desarrollo afectivo-emocional:
Premios
y
castigos:
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VII.

Enfermedades
y/o
accidentes
significativos:
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Antecedentes
clnicos
y
psicopatolgicos:
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HISTORIAL ACADMICO.
- Ingreso a Nido:
- Relacin
con
compaeros:
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-

Relacin
con
las(os)
cuidadores(as):
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Ingreso a Educacin Inicial:

- Relacin
con
sus
profesores(as):
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- Aprendizaje:
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- Relacin
con
sus
compaeros(as):
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Ingreso a Educacin Primaria:

- Relacin
con
sus
docentes:
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- Relacin
con
sus
compaeros(as):
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- Rendimiento acadmico: ____________________________________________________________
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- Conducta
durante
la
estada
en
el
Colegio:
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- Participacin
en
las
actividades
del
Colegio:
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- Colaboracin
de
los
padres:
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- Le agrada su Colegio?: ____________________________________________________________
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VIII.

Percepcin
del
educando
de
cmo
fue
su
primaria:
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Ingreso a Educacin Secundaria:

- Relacin
con
sus
docentes:
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- Relacin
con
sus
compaeros(as):
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- Rendimiento acadmico: ____________________________________________________________
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- Conducta
durante
la
estada
en
el
Colegio:
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- Participacin
en
las
actividades
del
Colegio:
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- Colaboracin
de
los
padres:
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- Le agrada su Colegio?: ____________________________________________________________
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- Percepcin
del
educando
de
cmo
fue
su
secundaria:
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Educacin tcnica superior:

- Proceso
de
eleccin
de
la
carrera:
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- Ingreso
a
Entidad
tcnica
Superior:
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- Cambios de carrera: __________________________________________________________________
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- Desempeo acadmico: ____________________________________________________________
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- Socializacin:
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- Problemas frecuentes: ________________________________________________________________
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- Percepcin
del
educando
de
cmo
fue
su
primaria:
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ANTECEDENTES LABORALES:

Cmo fue su primer empleo: ____________________________________________________________

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Cuntas veces ha laborado: ____________________________________________________________
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Razones
por
las
que
suele
salir
de
sus
empleos:
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Cunto
suele
durar
en
sus
empleos:
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Se
siente
a
gusto
en
su
actual
empleo:
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Relacin
con
sus
compaeros(as)
de
trabajo:
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Aspiraciones laborales: __________________________________________________________________
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IX.HISTORIA PSICO-SEXUAL:
- Cmo afront los cambios de la pubertad (voz, vellos, desarrollo muscular, estados de
nimo):
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Menstruacin (para mujeres): (a qu edad comenz, cmo lo tom, qu piensa de ello, es

regular o irregular )
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Eyaculacin (para varones): (a qu edad comenz, cmo lo tom, qu piensa de ello, es

regular o irregular)
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Masturbacin (a qu edad comenz, con qu frecuencia, qu piensa de ello):

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Suele conversar con sus padres sobre temas sexuales:

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Recibe orientacin de otras personas sobre temas sexuales:

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A qu edad se sinti atrada por el sexo opuesto:

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Enamoramiento(os): (si ya ha tenido enamorado(a), cuntos(as), qu tal le fue)

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Relaciones de pareja:
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Relaciones coitales: (a qu edad las tuvo, con qu frecuencia, qu opina de ello)

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Mtodos anticonceptivos: (suele usarlos, qu opina de ellos, cuntos conoce)

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Orientacin sexual en el Colegio:

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Aborto: (si lo ha realizado, qu opina al respecto)

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Ideal de familia:
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X. SUEO:
- Cuntas
horas
duerme
al
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da:

Dificultades
para
conciliar
o
mantener
el
sueo:
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Con
qu
frecuencia
se
presentan
esas
dificultades:
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Con
cuntas
personas
duerme
en
su
habitacin:
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Hbitos
de
sueo:
(televisin,
luz
prendida,
comodidad,
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etc.)

XI.EXPECTATIVAS RESPECTO A LA VIDA.

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