# de Historia:
Fecha:
ENTREVISTA INFANTIL
I. Datos de Identificacin del Paciente
Nombres y Apellidos: _________________________________________________
Lugar y Fecha de nacimiento: __________________________________________
Edad: ____________ Sexo: ________________ C.I: __________________
Escuela: ____________________________________________________________
Grado: ______________ Turno: _________________ Repite: ________________
Docente: ___________________
II. Datos de Identificacin del Familiar o Representante
Madre:
Nombre y Apellido: __________________________________________________
Lugar y Fecha de Nacimiento: __________________________________________
Edad: _____________ C.I: _____________________________________________
N de hijos: ____________________ Estado Civil: __________________________
Grado de instruccin: ________________________________________________
Profesin: _________________________ Trabajo: _________________________
Direccin: __________________________________________________________
Padre:
Nombre y Apellido: __________________________________________________
Lugar y Fecha de Nacimiento: __________________________________________
Edad: _____________ C.I: _____________________________________________
N de hijos: ____________________ Estado Civil: __________________________
Grado de instruccin: ________________________________________________
Profesin: _________________________ Trabajo: _________________________
Direccin: __________________________________________________________
Representante:
Nombre y Apellido: __________________________________________________
Lugar y Fecha de Nacimiento: __________________________________________
Edad: _____________ C.I: _____________________________________________
N de hijos: ____________________ Estado Civil: __________________________
Grado de instruccin: ________________________________________________
Profesin: _________________________ Trabajo: _________________________
Direccin: __________________________________________________________
III. Motivo de Consulta
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IV. Antecedentes Pre Para y Post Natales:
Embarazo:
ESTADO PSICOLGICO: ____________________________________________________________________
HIJO DESEADO: __________SEXO DESEADO: _______ EMB. NORMAL: ___________________________
CONTROLADO: _____________ N DE SEMANAS: ______________________________________________
COMPLICACIONES EN EL EMBARAZO: _______________________HIPERTENSIN: _______________
EDEMA: __________ AMENAZA DE ABORTO: ___________ ABORTOS: ___________________________
CAUSAS: ________________________TRAUMATISMOS: ______ CONFLICTO RH: ___________________
RADIOTERAPIAS: _____________________ OTROS: ____________________________________________
TRATAMIENTOS MEDICOS RECIBIDOS: _____________________________________________________
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Parto:
NORMAL: ____________ A TERMINO: __________ INDUCIDO: ___________ PREMATURO: __________
CESAREA: ________ POR QUE?: _____________________________________________________________
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Complicaciones:
RUPTURA PRECOZ DE MEMBRANA: ___________________ TRAUMATISMOS: __________________
CIRCULAR DE CORDN: ___________________________FRCEPS: _______________________________
Condiciones del recin nacido:
PRESENTACIONES AL NACER: CEFLICO: _______ PODLICO: _______ CIANTICO: ____________
ICTERICO: ___________ CONVULSIONES: ___________ DIFIC. DE SUCCIN: ______________________
DIFIC. PARA LLORAR: __________________ REANIMACIN: ____________________________________
INCUBADORA: _____________________OXIGENO:_____OTROS:_____________________________
PESO Y TALLA AL NACER:__________________________________________________________________
TRATAMIENTO MEDICO: __________________________________________________________________
Desarrollo Evolutivo:
ALIMENTACIN PRIMER AO DE VIDA:____________________________________________________
EDAD DEL DESTETE:_____________________ LEVANTO LA CABEZA:______________________
CAMIN:___________ SE SENT:___________GATE:____________ SE PAR:_____________________
Desarrollo del Lenguaje:
VOCALIZACIONES: ________SILABACIONES: _________________________BALBUCEO: ____________
PRIMERAS PALABRAS CON SIGNIFICADO: ______________________FRASES: _______________
ORACIONES: ______________ PRESENTA ALGUNA DIFIC. DE LENGUAJE: ________________________
DE QUE TIPO: ______________________________ OYE BIEN: ____________________________________
COMPRENDE TODO LO QUE SE LE DICE: _________________ OTROS: ____________________________
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V. Condiciones Generales de Salud
CONDICIONES DE SALUD DURANTE EL PRIMER AO DE VIDA: ________________________________
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Enfermedades Significativas:
SARAMPIN:_____ RUBOLA:_______ TOS FERINA:______ PAPERAS:______ LECHINA:______
MENINGITIS:_________ ENCEFALITIS:________ CONVULSIONES:_______ EPILEPSIA:________
OTITIS CRNICA:______________ T.C.E. TRAUMATISMO CRANEOENCEFLICO:____________
CARDIOPATIAS:________ DOLORES DE CABEZA PERIODICOS:________ DESMAYOS:_____________
INTERVENCIONES QUIRRGICAS: ________________________________________________________
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TRATAMIENTOS MDICOS QUIRRGICOS: ________________________________________________
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Exmenes:
E.E.G.(FECHA Y RESULTADOS): _____________________________________________________________
RADIOGRAFIAS:___________________________________________________________________________
OTROS: ___________________________________________________________________________________
ACCIDENTES: ____________________________________________________________________________
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CONTROL PEDITRICO
SI________ NO________
CONDICIONES ACTUALES DE SALUD: _____________________________________________________
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VI. Hbitos
SUEO:
N DE HORAS QUE DUERME: ______________ SE ACUESTA VOLUNTARIAMENTE:___________
DUERME SOLO:______ ACOMPAADO:________
ALIMENTACIN:__________________________________________________________________________
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ASEO PERSONAL: ________________________________________________________________________
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VII. Control de Esfnter:
VESICAL: ________________________________________ANAL: __________________________________
MTODO EDUCATIVO: ____________________________________________________________________
PROBLEMAS SURGIDOS: ___________________________________________________________________
VIII. Sntomas Neurticos
ENURESIS DIURNA:______________ NOCTURNA:_____________ OCASIONAL: _____________
ENCOPRESIS DIURNA:____________ NOCTURNA:____________ OCASIONAL: _____________
ONICOFAGIA SI__________ NO__________SUEO NORMAL______
INTRANQUILO______ TERROR NOCTURNO_______ INSOMNIO______ DUERME DEMASIADO______
SONAMBULISMO______ BRUXISMO_______ PESADILLAS_____________________________________
CHUPARSE EL DEDO______MORDERSE LOS LABIOS______ SUCCIONARSE LA LENGUA__________
SE HALA LAS OREJAS, EL PELO, LA NARIZ_________ SE FROTA LOS OJOS_______________________
MOVIMIENTOS ROTRICOS DE LA CABEZA________ TICS NERVIOSOS_________________________
GOLPEA LA CABEZA CON LAS MANOS__________ CURIOSIDAD SEXUAL_______________________
IX. Escolaridad
INGRESO AL PREESCOLAR: _________________________ADAPTACIN: _________________________
EDUCACIN BSICA: ______________________________________________________________________
RENDIMIENTO GENERAL:__________________________________________________________________
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DIFICULTADES PRESENTADAS: ____________________________________________________________
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REPITENCIAS: _______________________CUAL (ES) GRADO (S):_________________________________
RAZONES DE REPITENCIA:_________________________________________________________________
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CONDUCTA EN LA ESCUELA: ______________________________________________________________
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CON LOS COMPAEROS: __________________________________________________________________
CON LA MAESTRA: ________________________________________________________________________
ACTITUD HACIA LOS ESTUDIOS: ___________________________________________________________
HORARIO ESTABLECIDO PARA REALIZAR SUS ACTIVIDADES ESCOLARES: ____________________
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REALIZA SUS TAREAS SOLO O CON AYUDA: _________________________________________________
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REALIZA SUS ACTIVIDADES ESCOLARES EN LUGAR ADECUADO:_____________________________
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SE DISTRAE CON FACILIDAD: Si ___________ No _______________
EXPLIQUE: _______________________________________________________________________________
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CUENTA CON MATERIAL DE APOYO NECESARIO PARA REALIZAR SUS ACTIVIDADES
ESCOLARES:______________________________________________________________________________
ASISTE CON REGURALIDAD A LA ESCUELA:_________________________________________________
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N DE PLANTELES EDUCATIVOS Y NOMBRE DONDE HA REALIZADO SU ESCOLARIDAD
PBLICOS:________________________________________________________________________________
PRIVADOS:_______________________________________________________________________________
X. rea Socio-Emocional
PERSONALIDAD DEL NIO/A:
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RELACIONES INTERPERSONALES DE(L) (LA) NI@ DENTRO DEL GRUPO FAMILIAR CON PAREJA
PARENTAL: ______________________________________________________________________________
HERMANOS: ______________________________________________________________________________
OTROS FAMILIARES: ______________________________________________________________________
RELACIONES INTERPERSONALES DE(L) (LA) NI@ FUERA DEL GRUPO FAMILIAR (COMPAEROS
Y OTROS) _________________________________________________________________________________
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ACTIVIDADES QUE REALIZA EL (LA) NI@ (JUEGOS, DIVERSIONES, DEPORTES Y OTROS)
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XI. Dinmica Familiar (interna y social)
RELACIONES INTRAFAMILIA (CONYUGALES, VNCULOS CON LOS HIJOS Y OTROS HERMANOS,
AMBIENTE FAMILIAR ACTUAL): ____________________________________________________________
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XII. Genograma
XIII. Antecedentes Patolgicos Familiares
LNEA MATERNA: _________________________________________________________________________
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LNEA PATERNA: _________________________________________________________________________
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XIV. Condiciones Fsico Ambientales
TIPO DE VIVIENDA: _______________________________________________________________________
TENENCIA DE LA VIVIENDA: _______________________________________________________________
DISTRIBUCIN DE LA VIVIENDA: ___________________________________________________________
QUIENES TRABAJAN:______________________________________________________________________
QUIENES APORTAN:_______________________________________________________________________
N DE FAMILIARES QUE HABITAN: __________________________________________________________
XV. Condiciones Socio Econmicos
DISTRIBUCIN DE GASTOS O EGRESOS:
INGRESO MENSUAL_______________________________________________________________________
INGRESO MENSUAL FAMILIAR_____________________________________________________________
GASTOS QUE USTED REALIZA:
ALIMENTACIN: _________________________________________________________________________
VIVIENDA: ______________________________________________________________________________
ALQUILER: ______________________________________________________________________________
SERVICIOS PBLICOS: ____________________________________________________________________
AGUA:_______________ GAS:______________ TELFONO:______________________________________
ELECTRICIDAD___________ EDUCACIN: ___________________________________________________
ACTIVIDAD RECREATIVA: _________________________________________________________________
OTROS:___________________________________________________________________________________
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XVI. Impresin Del Entrevistado
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XVII. Observaciones
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