HISTORIA PSICOPEDAGOGICA DEL ADOLESCENTE

I.-FICHA DE IDENTIFICACIÓN

Nombres y
Apellidos_____________________________________________________________________

Sexo_________________ Edad________________
DNI___________________________________
Grado y Sección________________________________
Fecha de nacimiento______________________
Lugar de nacimiento_____________________________
N° de hermanos _________________________________________
Lugar que ocupa entre los hermanos_____________________
Dirección
actual_______________________________________________________________________
Lugar de procedencia_____________________________________________________
Teléfono (s)_______________________________________________________________

Fecha de la
entrevista____________________________________________________________________
Nombre del
Psicólogo____________________________________________________________________

Informante(s)
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II.-DATOS FAMILIARES

Apellidos y nombres Edad Estado Grado de Ocupación Religión

civil instrucción
Padre

Madre

Apoderado
III.- ANTECEDENTES FAMILIARES

Enfermedades
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Embarazo : Planificado ( ) No planificado ( )

Parto: Casa ( )
C.S. ( )
Hospital ( )

Problemas en el habla (si) (no)_____________________________________________

Intervención quirúrgica (si) (no)___________________________________________

Medicado (si) (no)_______________________________________________________

Epilepsia (si) (no)________________________________________________________

Alergias (si) (no)_________________________________________________________

Convulsiones (si) (no)____________________________________________________

RM (si) (no)____________________________________________________________

Asma (si) (no)___________________________________________________________

IV.-OBSERVACIONES GENERALES

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V.-MOTIVO DE CONSULTA
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VII.- FAMILIA Y RELACIONES SOCIALES
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VIII.- ANTECEDENTES DE CONDUCTA SEXUAL

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IX.- HISTORIA ESCOLAR

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