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PSIQUIATRA INFANTO-JUVENIL
HOSPITAL DR. GUSTAVO FRICKE
Entrevista Anamnesis
I.- IDENTIFICACION:
Nombre
Completo:.............................................................................................
Edad:..........................................................................................................
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Fecha de
Nacimiento:..........................................................................................
Nmero Ficha:
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Rut:..
Colegio:.......................................................................................................
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Profesor jefe:
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Curso:.........................................................................................................
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Escolaridad:................................................................................................
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Curso de
Repitencia:..............................................................................................
Rendimiento
Promedio:..........................................................................................
Datos entregados
por:.............................................................................................
Fono:
DEPARTAMENTO DE PSICOPEDAGOGA
PSIQUIATRA INFANTO-JUVENIL
HOSPITAL DR. GUSTAVO FRICKE
Celular:
Correo electrnico:.
Fecha de
Entrevista:.................................................................................................
DEPARTAMENTO DE PSICOPEDAGOGA
PSIQUIATRA INFANTO-JUVENIL
HOSPITAL DR. GUSTAVO FRICKE
Cul es el motivo de su
consulta?------------------------------------------------------------
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Cmo tratan de
superarla?--------------------------------------------------------------------
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Expectativas frente al
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Nombres:...............................................................................................
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Edad:......................................................................................................
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Escolaridad:...........................................................................................
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Caractersticas Relevantes:
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Anemia Irradiaciones:
Hipertensin: Hemorragias:
Toxemia: Sarampin:
Trastornos Renales: Vmitos:
Trastornos Cardiacos: Accidentes:
Desmayos: Problemas Emocionales:
Alergias:
Llor enseguida?
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Se us el Oxgeno?
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Anoxia:
Incompatibilidad Sangunea RH:
DEPARTAMENTO DE PSICOPEDAGOGA
PSIQUIATRA INFANTO-JUVENIL
HOSPITAL DR. GUSTAVO FRICKE
Recambio de Sangre:
Aumento o Prdida de peso:
Reflejos:
Ha padecido:
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Qu cosas lo enfurecen?
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Muestra autocontrol?
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DEPARTAMENTO DE PSICOPEDAGOGA
PSIQUIATRA INFANTO-JUVENIL
HOSPITAL DR. GUSTAVO FRICKE
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XI.-ACTIVIDADES RECREATIVAS:
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Plan de Evaluacin:
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