ANAMNESIS
NP de historia,
Apelides y Nombres Se
Fecha y Lugar de nacimiento :_
Edad (aios y meses) ee
Grado de insiruccién
|. DATOS GENERALES
Informantels) i
Nombre y Apelidios Edad | Grado deinsiweciin | Ocupacén
a [
[Loraare |
[Hermanas |
| [
[
| I
Il, MOTIVO DE CONSULTA
1, @Cémo se presento esta dificullod? gDesde cudndo® gQuién lo detecié#
2, gCudndo, dénde y con quién se presenta el problema?
3, 2Cémo ha evoucionado desde que aparecié por primera vez? zHa notade alguna mejeria?
4, @Qué es lo quese ha intentado para solucionar este prablema? Diagndstica (si lo tuviera}
5, Segtin usted, gCudl es la causa del problema# gCudies la aciitud frente alproblemo?
4, Tratamiento recibidos ¢Cudnta tiempo? gEn qué institucianes? Evolucién del tratamiento
Enfermedad octual
Tiempo de sindrome : ( Loos i ( I dios
Forma de inicio ( Pbrusca —{_Jinsidioso (J nacimiento
Signosy sintomas principales
Estresores importantes (ave quordan relacién con él problema del pacenle. con las
cousas que devencodenan conductasinapropiodas© qus agraven el problema}
rotamienios formacoldgcos (ulliza medicomentos necesarios v obigareries, especificar
‘cudles, las dasis, horarios y método administracion del o los medicamentos que utiliza) IIL, HISTORIA EVOLUTIVA:
1. PRE- NATAL
gCudl el nmera de embarazo con su hijo?
2Cémo fue su embarazo 0 gestacién (condiciones) ? Sintomas, problemas, duracién,
aFue planificade 0 deveado?
Tipo de control imédico [ porter, i a
Enfemedades durante el embaraz, dilicullades y/o
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