FORMATO HISTORIA CLINICA..doc

HISTORIA CLINICA I.- FICHA DE IDENTIFICACION NOMBRE:____________________ NOMBRE:________________________________ _________________________ _________________________ _____________  _  SEXO:_____________________ SEXO:_________________________EDAD: ____EDAD: ________________________ ______________________________  ______  LUGAR Y FECHADE NACIMIENTO: ________________________ ____________________________________ _____________  _  ESCOLARIDAD:_________________ ESCOLARIDAD:_____ ________________________ ________________________ ________________________  ____________  DOMICILIO: ________________________ ____________________________________ ________________________ ____________________  ________  RELIGION:____________________ RELIGION:________ ________________________ ________________________ _________________________  _____________  ESTADO CIVIL:____________ CIVIL:_ ________________ _____ OCUPACION: ________________________  _____________ ___________  NUMERO DE HIJOS (Edades):___________________ (Edades):_______________________________ ______________________  __________  FECHA DE ESTUDIO:____________________ ESTUDIO:________________________________ ________________________ ________________  ____ 

II.- MOTIVO DE CONSULTA (Problema): •

MANIFIESTO:

 _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ _______________________  ___________ 

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LATENTE:

 _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ _______________________  ___________ 

III.- APARIENCIA GENERAL PORTE ! ACTITUD ("e#$r%&$%' bree *+e "e,e +a %m&re#%' "el &a$%ee):  _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________________ _____________________________  _________ 

IV.IV.- FAMILIO FAMILIOGRAMA: GRAMA:

V.V.- PADECIM PADECIMIENTO IENTO ACTUAL:                                                

VI.- HISTORIA FAMILIAR: DEL PADRE:  _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________________ _____________________________  _________  •

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DE LA MADRE:

 _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________________ _____________________________  _________ 

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HERMANOS:

 _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________________ _____________________________  _________  •

 ABUELOS PA PATERNOS: TERNOS:

 _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________________ _____________________________  _________  •

 ABUELOS MATERNOS: MATERNOS:

 _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________ ________________________ _________________  _____   _______________________  ___________________________________ ________________________________ _____________________________  _________ 

VII.- HISTORIA PERSONAL PERSONAL (A#&e$o# a $o#%"erar: /0am%l%ar /e#$olar /e#$olar /#o$%al /laboral /#e1+al /me"%$o.) •

CONCEPCION ! EM2ARA3O

 A e!"e#a#se a $ad#e e$%a#a&ada e$%a#a&ada de 'ae!"e a s"*a+! s"*a+! de a ,a$a e#a Es"a%e ( ) !es"a%e ( ) sa"s,a"-#a ( ) .Ha%/a 'a!ead- "e!e# ese !0-1 ______________________ _______________________________  _________  .C*2 e#a a ds'-s+! de "e!e# a !0-3 "a!"- de 'ad#e -$- de a $ad#e1  ________________________  ____________________________________ _________________________ ___________________  ______  .C*2 se4- '#e,e#/a 5*e ,*e#a1_______________ ,*e#a1_______________ ."e#$!- e e$%a#a&- a "e$'-1  ____ .C*2 ,*e a sa*d sa*d de a $ad#e d*#a!"e e e$%a#a&-1 e$%a#a&-1 _____  .T*6- 6+$"-s1______ .sa!7#ad-1______ .sa!7#ad-1______ .!e#6-ss$-1 _____ a*$e!"- de 'es- e4a7e#ad-1 _____ .8*9 '#-%e$a "*6- d*#a!"e e e$%a#a&-1 ___   ________________________  ____________________________________ _________________________ ___________________  ______  •

NACIMIENTO

.C+$- ,*e e 'a#"-1 Es'-!"2!e- ( ) !d*d- ( ) es2#ea ( ) .Se *"&- a!es"esa1_______ .de 5*e "'-1_____ .se *" &a#-! ,+#e's1____ des#%a s*s #e*e#d-s ae#a de 'a#"- ______________   ________________________  ____________________________________ _________________________ ___________________  ______  .C*2!"as -#as d*#- e "#a%a;- de 'a#"-1________ .*%- -$'a-!es1  _______ .C*2es1__________ .C*2es1______________________ _________________________ ____________________ _______ .C*2!"'es- e !0- a !ae#1_________ .!a+ !-#$a1_________ !-#$a1_________ .!a+ $-#ad-1  _____ .#es'#- '#-!"-1______ '#-!"-1______ .C*2 ,*e a '#$e#a #ea+! - $'#es+! $'#es+! de a $ad#e a 6e# a %e%e1 ___________________________  ___________________________   ________________________  ____________________________________ _________________________ ___________________  ______ 

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ALIMENTACION

Se e a$e!"- a 'e- ( ) - -! %%e#+! ( ) .C*2!d- se e e$'e&+ a da# -"#- a$e!"-1 ______________ ______________ .C*2!d- se e 5*"e 'e- de,!"6a$e!"e1 _________________ .C*2 ,*e a # ea+! de !0*a!d- e 5*"a#-! e 'e-1  ________________________  ____________________________________ _________________________ ___________________  ______  .H*%- +-s1________ .8*9 "a! ,#e*e!"es1 ___________________ ___________________ .a9#7a a$e!"-s1 ______________________ ______________________ !d5*e 5*e s *%- -"#as -$'a-!es e! e 2#ea a$e!"a1 _______________________  _______________________   ________________________  ____________________________________ _________________________ ____________________  _______  .C*a!d- se e 5*"- de,!"6a e *"$- %%e#+!1________.e4'5*e %%e#+!1________.e4'5*e -$- e#a e a'e""- de $e!-# < -$- a sd- as"a e '#ese!"e1 ____________   ________________________  ____________________________________ _________________________ ___________________  ______  .F*e - a sd- !eesa#- ,-#&a# a a$e!"a+!1 _____________________  _____________________  •

SUE4O

.F*e - a sd- !5*e"- a d-#$#1____ .a 5*e edad d*#$+ '-# '#$e#a 6es s! !"e##*'-!es d*#a!"e "-da a !-e1_________________ !-e1____________________________ ___________ .Es s-!2$%*- - - a sd-1____.a 5*e edades1______.a edades1______.a '#ese!"ad- #ess"e!a 'a#a # a a a$a1_______.a%a d*#a!"e e s*e0-1_____.se des'e#"a%a 7#"a!d-1_____.de 7#"a!d-1_____.de '-#5*e1______ .de "e!e# 'esadas1_   ________________________  ____________________________________ _________________________ ___________________  ______  .C-! 5*e! a d-#$d- d*#a!"e as d,e#e!"es edades1_______________  edades1_______________   ________________________  ____________________________________ _________________________ ___________________  ______   ________________________  ____________________________________ _________________________ ___________________  ______  .E! a $s$a a$a1____ .a "e!d- - "e!e " e!e $ed- de d-#$# s--1______  •

ENTRENAMIENTO ENTRENAMIENTO DE ESFINTERES

.C*2!d- e$'e&+ a ed*a#- 'a#a 5*e ,*e#a a %a0-1__________________ %a0-1__________________ .C*a!d- es"*6- -$'e"a$e!"e ed*ad- 'a#a 5*e ,*e#a s--1___________ s--1___________ .5*e $9"-d-s *sa#-! 'a#a es"a ed*a+!1_______________ ed*a+!1________________________  _________  .U!a 6es 5*e a'#e!d+ a'#e!d+ 6-6+ a -#!a#se e! a a$a - e! -s 'a!"a-!es1 'a!"a-!es1  ________________________  ____________________________________ ______________________  __________  •

DESARROLLO DEL LENGUA5E

.A 5*e edad "#a"- de da#se a e!"e!de#1_________.a 5*e edad d;- 'aa%#as '-# '#$e#a 6es1_____________ 6es1_____________ .8*9 'aa%#as1____________  'aa%#as1____________   ___________________  ___________________ .A 5*e edad d;- ,#ases - -7#- *!# *!# 'aa%#as1 __   __________ .a 5*e 5*e edad !-"a#-! 5*e "a#"a$*dea#/a3 "a#"a$*dea#/a3 s se '#ese!"- es"e es"e '#-%e$a1_______________  •

DESARROLLO MOTOR

.A 5*e edad -7#- s-s"e!e# a a%e&a1_______ a%e&a1_______ .A 5*e edad -7#- 6-"ea#se s--1  ______ .A 5*e edad se se!"+ se!"+ -! a<*da1 ________ ________ .Y s! a<*da1 a<*da1 __ ______ .a 5*e edad 7a"e-1______ .A 5*e edad -7#- '-!e#se de 'e1____ .A 5*e edad -7#- a$!a# -! a<*da1________.S! a<*da1________.S! a<*da1________.C-$a<*da1________.C-$- ,*e a "#a69s de s* #e$e!"-1_______ #e$e!"-1___________________ ________________________ _______________  ___   ________________________  ____________________________ ____ .C*2es as sd- < s-! s*s a"6dades a"6dades ,/sas '#e,e#das1___________________ '#e,e#das1_______________________________ ________________________ _____________  _ 

.A 5*e edad e$'e&+ a a!da# e! "#-1________ .A 5*e edad a'#e!d+ a a!da# e! %e"a1____________  %e"a1____________  •

DESARROLLO SE6UAL

.A 5*e 5*e edad se d- *e!"a *e!"a de a d,e#e!a e!"#e as !0as < -s !0-s1______ .C-$- - e4'#es-1__________________ e4'#es-1______________________________ ________________________ ______________  __  .C*2!d- < -$- $-s"#+ *#-sdad s-%#e s-%#e e -#7e! de -s !0-s1___________  !0-s1___________   ________________________  ____________________________________ _________________________ ______________________  _________  .C+$- #es'-!de#-! -s 'ad#es a es"a *#-sdad1______________________  *#-sdad1______________________   ________________________  ____________________________________ _________________________ ______________________  _________  .a 5*e edad !-"a#-! -s 'ad#es 5*e e $e!-# "*6e#a "e!de!a a "-a#se -s +#7a!-s 7e!"aes1_________________ 7e!"aes1_____________________________ ________________________ _______________  ___  .C+$- $a!e;a#-! -s 'ad#es es"as "e!de!a1________________________  "e!de!a1________________________   ________________________  ____________________________________ _________________________ ______________________  _________  .C-! *a $e$%#- de a ,a$a se !-"- 5*e e $e!-# "e!d/a a -'a# a $a!e#a de se#1_____________________ se#1_________________________________ _________________________ ___________________  ______  .8*9 '#e'a#a+! se e d- a $e!-# ae#a de - se4*a1________________  se4*a1________________  .E! as- de se# !0a se e '#e'a#- 'a#a a '#e'a#a+!1________________ '#e'a#a+!1_________________  _  .E! as- de se# !0- se e '#e'a#- 'a#a as '#$e#as e
HISTORIA ESCOLAR

.A 5*e edad se e e6- '-# '#$e#a 6e& a ;a#d/! de !0-s - a a es*ea1_____   _____________________  _____________________ .C+$- #ea-!-1_____________ #ea-!-1_______________________  __________  .C*2 ,*e s* a'#-6ea$e!"a'#-6ea$e!"- es-a# e! -s d,e#e!"es 7#ad-s1___________   ________________________  ____________________________________ _________________________ ______________________  _________  .C+$- se #ea-!- -! s*s -$'a0e#-s de es*ea1____________________  es*ea1____________________   ________________________  ________________________________ ________ .Y -! -! s*s $aes"#-s1 _________  _________   ________________________  ____________________________________ _____________________ _________ .-$.-$- se s!"e#-! -s 'ad#es aa -s 94"-s < ,#aas-s 5*e e $e!-# "*6- e! a es*ea1______   ________________________  ____________________________________ _________________________ ______________________  _________  .C*2es s-! as $a"e#as 5*e $as se e a! d,*"ad-1__________________  d,*"ad-1__________________   ________________________  ____________________________________ _________________________ ______________________  _________ 

•

HISTORIA DE LA SALUD

.8*9 e!,e#$edades a '#ese!"ad- < a 5*e edades1____________________  edades1____________________   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ ________________  ___  .8*9 "#a"a$e!"- se e  e d- a es"as e!,e#$edades1________________ e!,e#$edades1_____________________  _____   ________________________  ____________________________________ _________________________ _______________________  __________  .8*9 ade!"es a "e!d- < a 5*e edades1______________ edades1___________________________  _____________ 

 ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _______________  __  .8*9 e,e"-s '#-d*;e#-! es"as e!,e#$edades - ade!"es e! a 'e#s-!a < e! a ,a$a1 ______________________ __________________________________ _________________________ _________________  ____   ________________________  ____________________________________ _________________________ _______________________  __________  .Ha es"ad- a7*!a 6e& -s'"a&ad-1 _______ .P-# 5*91 _______________   ________________________  ____________________________________ _________________________ _______________________ __________ .C*2!d-1 _______________________ ___________________________________ ________________________ ________________  ____  .F*e se'a#ad- de -s 'ad#es d*#a!"e a -s'"a&a+!1 ____________ .8*9 se e d;- a $e!-# ae#a de a -s'"a&a+!1 ______________________  ______________________  .a s*,#d- -'e#a-!es1 _____ e4'5*e ______________________ ____________________________  ______   ________________________  ____________________________________ _________________________ _______________________. __________.A A s*,#d- 'ade$e!"-s de!"aes -$'ad-s1__________ -$'ad-s1__________ e4'5*e ______   ________________________  ____________________________________ _________________________ ______________________  _________  •

DESARROLLO DE LA PERSONALIDAD:

.e 7*s"a%a a $e!-# a%#a&a# a s* $ad#e desde -s '#$e#-s $eses1_________  .a -"#as 'e#s-!as1 ________ .#es'-!d/a -! 7*s"- *a!d- s*s 'ad#es se ae#a%a! - se a%#a&a%a!1 ________ .a 5*e edad se s-!#+ '-# '#$e#a 6e&1  ______ .a 5*e edad edad se !-"- 5*e a s-!#sa s-!#sa aa a $ad#e e#a $as !"e!sa !"e!sa < d,e#e!"e (5*e a #e-!-/a)1 ________ .a 5*e edad se !-"- 5*e $-s"#a%a #ea+! de $ed- ,#e!"e a -s e4"#a0-s1 _________ .8*9 "a! !"e!sa$e!"e e4'#esa%a s*s se!"$e!"-s *a!d- e#a 'e5*e0-1________________ 'e5*e0-1________________ .< e! a a"*adad1 __________________________ __________________________ .C+$- ,*e #ea-!a!d- a d,e#e!"es edades *a!d- se e !e7a%a a7- - !- se e da%a 7*s"- e! a7-1 ___   ________________________  ____________________________________ _________________________ ______________________  _________  .De 'e5*e0- '#ese!"- %e##!es1________ .8*e "a! ,#e*e!"e '#ese!"a%a %e##!es1 ________________________ ____________________________________ ___________________ _______ .L-s '#ese!"a e! a a"*adad1_______________ a"*adad1____________________.Se _____.Se 7-'ea%a 7-'ea%a a a%e&a -!"#a a 'a#ed 'a#ed - -!"#a e 's-1________________.8 's-1________________.8*e *e a/a! -s 'ad#es *a!d- e !0- "e!a %e##!es1_________________ %e##!es1_____________________________ __________________  ______   ________________________  ____________________________________ _________________________ ______________________  _________  .C+$- des#%e s* a#2"e# e! a a"*adad1 a"*adad1 ("e$'e#a$e!"- es"a%es3 es"a%es3 %e##!*d-3 $a*$-#ad-3 a,e"*-s-3 #ese#6ad-3 ae7#e3 e"=)_______________________ e"=)___________________________________ ________________________ ________________________ ________________  ____   ________________________  ____________________________________ _________________________ ______________  _ 

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PATRONES PATRONES DE 5UEGO 5UE GO

.8*9 ;*7*e"es '#e,e#d-s a "e!d- e! as d,e#e!"es edades1____________   ________________________  ____________________________________ _________________________ ______________________  _________  .8*9 -sa - a"6dad e !"e#esa%a - e !"e#esa1_____________________  !"e#esa1_____________________   ________________________  ____________________________________ _________________________ ______________________  _________  .Le 7*s"a! -s a!$aes1______ .C*aes '#e,e#e1___________________ '#e,e#e1____________________  _   _______________________  _______________________ .C+$.C+$- "#a"a < "#a"a%a a -s a!$aes1 a!$aes1 ______ 

 ________________________  ____________________________________ _________________________ ______________________  _________  .A $-s"#ad- #*edad aa -s a!$aes1_________________ a!$aes1___________________________  __________ 

•

DICIPLINA

.E! as d,e#e!"es edades3 5*e! a sd- #es'-!sa%e de s* -!d*"a1  ________________________  ____________________________________ ______________ __ .8*9! e $'*s- as -#de!es1 -#de!es1  ________________________  ______________________________ ______ .C+$- se a/a! a/a! -%edee# -s 'ad#es1 'ad#es1  ________________________  ____________________________________ _________________________ ______________  _  .8*9 as"7-s *"&a%a!1__________________ *"&a%a!1______________________________ _____________________  _________  .C+$- #ea-!a%a e $e!-# *a!d- se e as"7a%a1___________________  as"7a%a1___________________   ________________________  ____________________________________ _________________________ ______________________  _________ 

•

RELACIONES SOCIALES

.C-! 5*e! se #ea-!a%a e! ,-#$a $as e#a!a1________________ e#a!a1_____________________  _____   ________________________  ____________________________________ _________________________ _______________________  __________  .C+$- se #ea-!- -! s*s 'ad#es1_________________________ 'ad#es1________________________________  _______   ________________________  ____________________________________ _________________________ ______________________  _________  .C+$- se #ea-!- -! s*s a%*e-s1___________________________ a%*e-s1________________________________  _____  .C+$- se #ea-!- -! s* e#$a!-s(as)1________________________ e#$a!-s(as)1_____________________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________ .T*6.T*6- !a!a a7*!a a7*!a 6es1_______.C-$6es1_______.C-$- ,*e s* #ea+! -! -! ea1  ________________________  ____________________________________ ______________________  __________   ________________________  ____________________________________ _________________________ _______________________  __________  .C+$- ,*e a #ea+! -! s*s a$7-s1_____________________________ a$7-s1_______________________________  __   ________________________  ____________________________________ _________________________ _______________________  __________  .T*6- a7>! $e;-# a$7-1_______________________________________  .T*6- *! a$7- $a7!a#-1______ .as"a 5*e edad1___________________ edad1____________________  _  .E! 5*e a"6dades es-a#es 'a#"'a%a1_______________ 'a#"'a%a1___________________________  ____________   ________________________  ____________________________________ _________________________ _______________________  __________  .E! 5*e a"6dades s-aes 'a#"'a1_____________________ 'a#"'a1______________________________  _________  .E! 5*e a"6dades #e7-sas 'a#"'a - 'a#"'-1___________________ 'a#"'-1____________________  _   ________________________  ____________________________________ _________________________ _______________________  __________ 

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EVENTOS SIGNIFICATIVOS

.8*9 -sas $'-#"a!"es a! -*##d- d*#a!"e s* 6da1__________________  6da1__________________   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ ________________  ___  .Se'a#a-!es de 'e#s-!as $'-#"a!"es1____________ $'-#"a!"es1________________________ ________________  ____   ________________________  ____________________________________ _________________________ _______________________  __________ 

.Es"2! - as es"ad- se'a#ad-s -s 'ad#es1_______ 'ad#es1_______ .desde *a!d-1________ .P-#5*e1  ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _____________________  _________  .Ha a%d- de,*!-!es $'-#"a!"es e! a ,a$a1______ .De 5*!es1______   ________________________  ____________________________________ _________________________ _______________________  __________  .8*9 e,e"-s "*6e#-! s-%#e e - ea1_____________________________ ea1______________________________  _   ________________________  ____________________________________ _________________________ _______________________  __________  .8*9!es 66e#-! -! e e! a $s$a asa1 (!-$%#e3 'a#e!"es- < edad1______   ________________________  ____________________________________ _________________________ _______________________  __________   ________________________  ____________________________________ _________________________ ______________________  _________  N-$%#e de a 'e#s-!a 5*e -!"es"- < 'a#e!"es- -! e e4a$!ad-:  ________________________  ____________________________________ _________________________ ____________________  _______ 

VIII.- PROCESOS 2ASICOS: •

LENGUAJE:

 ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____  •

 ATENCION:  ATENCION:

 ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____  •

PERCEPCION:

 ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  __________________________________________ ______________________________ ________________________  ____________ 

•

MEMORIA:

 ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  __________________________________________ ______________________________ ________________________  ____________  ORIENTACION EN TIEMPO Y ESPACIO:  ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  __________________________________________ ______________________________ ________________________  ____________  •

•

JUICIO:

 ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  __________________________________________ ______________________________ ________________________  ____________  PENSAMIENTO:  ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  __________________________________________ ______________________________ ________________________  ____________  •

•

CONCENTRACION:

 ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  __________________________________________ ______________________________ ________________________  ____________ 

I6.- TECNICAS UTILI3ADAS PARA LA EVALUACION:  ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  __________________________________________ ______________________________ ________________________  ____________ 

6.- ACTITUD ANTE LA ENTREVISTA !7O APLICACI8N DE LAS PRUE2AS  ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  __________________________________________ ______________________________ ________________________  ____________ 

6I.- RESULTADOS E INTERPRETACION DE LAS PRUE2AS  ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  __________________________________________ ______________________________ ________________________  ____________   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  ____________________________________ _________________________ _________________________ _________________  _____   ________________________  __________________________________________ ______________________________ ________________________  ____________ 

6II.- INTEGRACION DE LOS RESULTADOS