Professional Documents
Culture Documents
1. Datos generales
nombre:
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Sexo:
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Edad:
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Escolaridad:
Religin:
Nombres de los padres y/o responsable, edad, escolaridad, ocupacin, estado civil:
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2. Motivo de consulta
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4. Historia personal (historia escolar y social)
Datos del periodo pre, peri y postnatal (condiciones anteriores al embarazo, parto)
Desarrollo psicomotor
Lenguaje
Alimentacin
Hbitos de sueo
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5. Perfil social
Relacin del paciente con personas fuera del grupo familiar o escolar
Habilidades o limitaciones y preferencias en cuanto a relaciones sociales
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6. Historia escolar
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5. Personalidad bsica
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6. Historia familiar
Genograma
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7. Examen mental
Resultado del examen mental (evaluacin de las funciones psicolgicas):
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8. Impresin clnica
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9. Focalizacin.
10. Jerarquizacin.
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11. Diagnstico:
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12. Fundamentacin de la impresin clnica o el diagnstico:
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b. Tcnicas a emplear
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Familiar:
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Escolar:
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Social:
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Nombre y firma del paciente
Nombre y firma del Profesional
que remite