Professional Documents
Culture Documents
IDENTIFICACION:
Nombre:__________________________________________________________________________
Fecha de nacimiento:_____________________________________________________________
Sexo: _________________________________________________________________________
Edad Actual:____________________________________________________________________
Domicilio: ____________________________________________________________________
Curso:
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Establecimiento: ________________________________________________________________
Datos entregados por:
Nombre: ______________________________________________________________________
Relacin estudiante: _____________________________________________________________
Fecha entrevista: _________________________________________________________________
Motivo de consulta:
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Describa las principales dificultades del nio:
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Antecedentes del desarrollo y salud del estudiante:
El nios tiene algn diagnostico previo.
Si
No
Cul?
Especialista.______________________________________________________________________
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Antecedentes Familiares:
Padres en unin o separados
Antecedentes Pre-natal:
Embarazo deseado o no, porque.
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Que dificultades ha tenido y tiene el nio en sus relaciones y juegos con los otros nios.
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Que le enfada
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Praxias
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Bucales__________________________________________________________
Linguales___________________________________________________________
Faciales____________________________________________________________
Antecedentes educacionales:
Asisti a sala cuna:_______________________________________________________
Asisti a jardn Infantil: ____________________________________________________
Como se integro a la escolaridad bsica:
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A cambiado de escuela: ____________________________________________________
Tubo dificultades para adquirir alguna materia, cual:
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Observaciones:
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Indicadores:
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Derivacin:
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Firma Entrevistado
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Firma Evaluador