ANAMNESIS FONOAUDIOLÓGICA

I. Antecedentes personalesa. Nombre: ____________________________________________________________________________b. Fecha de Nacimiento: _________________________________________________________________c. Edad: __________________________________________________________________________________d. Curso: _______________________________________________________________________________e. Colegio: _____________________________________________________________________________f. Motivo de consulta:

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g. Antecedentes del desarrollo:i. Periodo pre, peri y postnatal:

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ii. Motor: __________________________________________________________________________________________________________________________________________________________

iii. Lingüístico:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

iv. Psicoafectivo:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

h. Antecedentes del grupo familiar: __________________________________________________________________________________________________________________________________________________________________________________________

i. Antecedentes mórbidosi. Del niño:

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ii. De la familia:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

j. Fecha de la evaluación fonoaudiológica: _____________________________________________________________________________________________

k. Evaluaciones y tratamientos fonoaudiológicos previos: _____________________________________________________________________________________________

l. Malos hábitos orales:____________________________________________________________________________________________________________________________________________________________________________________

m. Antecedentes escolares: (rendimiento escolar en lgje., mat.; promedio de notas)_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

n. Otros antecedentes, observaciones:__________________________________________________________________________________________________________________________________________________________________________________________