ANAMNESIS

1.1 DATOS PARTICULARES DEL PACIENTE

Nombres:_________________________________________________________
Apellidos: _________________________________________________________
Direccin: _________________________________________________________
Lugar de nacimiento: ________________________________________________
Nombre del acudiente: ______________________________________________
Parentesco del acudiente: ____________________________________________
Fecha de anamnesis:________________________________________________
Nombre de examinador:______________________________________________
2.1 VARIABLES A CONSIDERAR
Sexo: ______________________
Edad: ____________

fecha de nacimiento: ______________

Grado de escolaridad: ____________________________________

Lateralidad: ____________________________
Etiologa: ______________________________________________
3.1 MOTIVO DE CONSULTA
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4.1 RELACIONES SOCIALES

5.1 HISTORIA CLNICA

Medica:
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Neurolgica:
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Psicolgica:
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Terapia de lenguaje:
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Observaciones:
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