Entrevista General Terapia Ocupacional

ENTREVISTA TERAPIA OCUPACIONAL ANTECEDENTES PERSONALES Nombre completo ___________________________________________________  Edad _____________________________________________________________  Estado Civil ________________________________________________________  Ocupación _________________________________________________________  Entrevistador y fecha entrevista: ________________________________________ 

ANTECEDENTES FAMILIARES Padre_____________________________________________________________  Madre ____________________________________________________________  Con quién vive______________________________________________________   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______  elación con !rupo familiar____________________________________________   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______  elación entre los padres _____________________________________________   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______  "eno!rama

ANTECEDENTES PSICOSOCIALES #ituación socioeconómica ____________________________________________  #ituación le!al ______________________________________________________  Ocupación padre e in!reso ____________________________________________  Ocupación madre e in!reso____________________________________________  Ocupación familiares e in!reso _________________________________________  $actores de ies!o %&$ ' ( M& ' ( )# ' ( O* ' ( +ro! ' ( )bandono ' ( %a!ancia %a!ancia ' ( Otro ______________________  +escripción________________________________________________________  _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______ 

HISTORIA CLÍNICA Periodo de Gestación  Naci!iento Embara,o de la madre _______________________________________________  Estado de -nimo ____________________________________________________   )ctitud de de la pare.a pare.a ____________ __________________ _____________ ______________ _____________ _____________ ____________  _____  Problemas en el embara,o ____________________________________________  Periodo !estación ___________________________________________________  /ipo de parto _______________________________________________________  Problemas en el nacimiento ___________________________________________  0actancia materna __________________________________________________  %1nculo con la madre ________________________________________________  %1nculo con el padre _________________________________________________  Otro ______________________________________________________________   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______ 

Desarro""o Psico!otor  Control de la cabe,a _________________________________________________  Posición sentado ____________________________________________________  "ateo ____________________________________________________________  Marcha ___________________________________________________________  Control esf1nter _____________________________________________________  Otro ______________________________________________________________ 

Ana!nesis +! actual__________________________________________________________  _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______  &nicio______________________________________________________________   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______  +esarrollo _________________________________________________________  _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______  /ratantes anteriores _________________________________________________  _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______  /ratamiento actual __________________________________________________   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______  $-rmacos 'nombre2 !rama.e2 dosis por d1a(  _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______ 

DESEMPE#O OCUPACIONAL R$tina diaria #emana___________________________________________________________   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______  $ines de #emana ___________________________________________________   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______ 

Ro"es %$e dese!&e'a  _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______ 

Dese!&e'o A(VD *i!iene menor ______________________________________________________  *i!iene mayor ______________________________________________________  Control esf1nter _____________________________________________________  3so del ba4o _______________________________________________________  %estimenta_________________________________________________________  Comer ____________________________________________________________  /raslado___________________________________________________________  +escripción ________________________________________________________   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______ 

Dese!&e'o AIVD Preparación alimentos _______________________________________________  Medicación ________________________________________________________  3so del teléfono ____________________________________________________  Cuidado de la casa __________________________________________________  Compras __________________________________________________________  3so transporte _____________________________________________________  Mane.o dinero ______________________________________________________  +escripción ________________________________________________________   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______ 

Dese!&e'o Descanso  S$e'o  _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______ 

Dese!&e'o Esco"ar  Curso y cole!io ____________________________________________________  *istoria escolar ____________________________________________________   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______  endimiento _______________________________________________________   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______  Conducta __________________________________________________________   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______  elación con compa4eros ____________________________________________   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______ 

Dese!&e'o )$e*o /ipo de .ue!o ______________________________________________________   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______  Compa4eros de 5ue!o _______________________________________________   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______ 

Dese!&e'o Ocio  Tie!&o "i+re  _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______ 

Acti,idades  ro"es de inter-s  _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______ 

Dese!&e'o Partici&ación Socia" elación con !rupos sociales __________________________________________   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______  elación con pares __________________________________________________   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______ 

Redes de a&oo $amilia y ami!os ____________________________________________________   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______  &nstituciones________________________________________________________   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______  Mapa de red 6 Ecomapa

Di.ic$"tades e" dese!&e'o oc$&aciona"  _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______ 

E/&ectati,as de Inter,ención  _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______ 

IMPRESI0N GENERAL Conducta manifestada _______________________________________________   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______  Contacto visual _____________________________________________________   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______  /ipo de comunicación ________________________________________________ 

 _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______  Cone7ión con la realidad _____________________________________________   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______  Postura corporal ____________________________________________________   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   )rre!lo personal personal _____________ ____________________ _____________ _____________ ______________ _____________ ____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______ 

Comentarios  _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______ 

&mpresión +ia!nóstica  _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______   _____________  ____________________ ______________ _____________ _____________ ______________ _____________ _____________ _____________  ______