Anamnesis Format
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ScribdTranslationsAnamnesis Format
Uploaded by
ScribdTranslationsAnamnesis Format
Personal background:
Student's name:
Date of birth: Age:
Address:
Family history:
Name of parent:
Occupation: Age:
Schooling: Work:
Mother's name:
Occupation: Age:
Schooling: Work:
No. Of children: Place occupied by the student:
Person with whom you live:
Responsible person:
Prenatal history:
Maternal diseases:
Medications (which ones):
Falls: Symptoms of miscarriage:
Nutritional status:
Emotional state:
Perinatal history:
Delivery: Weight: Size: Apt:
Problems during childbirth (which ones):
Postnatal history:
Postpartum treatments:
Major illnesses: Encephalitis: Meningitis:
Poliomyelitis: Tuberculosis: Hepatitis:
Operations - Hospitalizations (time):
Has suffered: Loss of consciousness:
Vision problems: Which ones? Wear glasses:
Hearing problems: Which ones?
Psychomotor Development: at what age?
I control my head: He sat down:
Stopped: Road:
I control sphincters:
Language development: at what age?
He said words: He said phrases:
Said prayers: I speak spontaneously:
Understood instructions:
Has needed evaluation: Psychological: when:
Neurological: when:
Psychiatric: when:
Psychopedagogical: when:
Habits
How many hours do you sleep:
He has trouble sleeping:
Possesses study habits:
What you entertain yourself with:
How many hours a day do you dedicate to the game:
Family relationships:
How is your relationship with your mother:
Father:
Siblings:
Other family members:
María Griselda Pimentel Sarmiento.
Educational Sciences with a major in Educational Psychology.
8vo. Semester "A".
October 23 - 2011.
