Comprehensive Therapeutic Support

Center
ANAMNESIS

INTERVIEW DATE _______________________________________________________________

1. PATIENT'S PERSONAL DATA

Names and surnames: ______________________________________________________
Age: _______________________ Date of Birth: dd / mm / yyyy
Place of birth: ______________________School: ______________Course: _____________
Sent by: __________________________________________________________________

2. REASON FOR CONSULTATION: ______________________________________________

3. FAMILY DATA
Family Structure (mark with an X)
Married Free Union Widower Single Mother Separated how long ago______
Observations:

Father
Name: _______________________________________ Profession: ___________________
Company: ____________________________________ Post: ________________________
Residential address: ____________________________ Phone: ______________________
Office address: ________________________________ Phone: ______________________
Email: _______________________________________ Cell phone: ___________________

Mother
Name: _______________________________________ Profession: ___________________
Company: ____________________________________ Post: ________________________
Residential address: ____________________________ Phone: ______________________
Office address: ________________________________ Phone: ______________________
Email: _______________________________________ Cell phone: ___________________

Number of brothers: _________________

Twin C Twin D
Name: _________________________ Age: ___________ Scholarship: ________________
Name: _____________ ____________ Age: _____ Scholarship: ________________
____________ Age:
____________
Name: _____________ _____ Scholarship: ________________
____________
Does anyone have difficulty in their schooling: Yes No
Which: ___________________________________________________________________

Number of half-siblings: _________________________

Name: _________________________ Age: _________ Scholarship: __________________
 Comprehensive Therapeutic Support
Center

Name: _________________________ Age: __________ Scholarship: ________________

Does anyone have difficulty in their No □
schooling: Yes
Which: _____________________________

Adoption (if applicable)

Institution: _________________________________________________________________
Adoption date:______________________________________________________________
General information upon delivery of the baby: ____________________________________

4. CLINIC HISTORY
Pregnancy and Childbirth
Do I use any type of fertility treatment: Yes or No or
Which: ___________________________________________________________________
Mother's age at pregnancy: ___________________________________________________
Any known problems during pregnancy (specify which and in what month of gestation): ____

Birth (mark with an X)

Normal U Cesarean section Full term U Premature U Induced U
Incubator Time: days months
Gestation weeks: ______________________________
Any complications during childbirth: Yes No
Which: ___________________________________________________________________
Did you take any medication during childbirth: Yes No [ ]
Which: ___________________________________________________________________
Postnatal History (from birth to first year)
Complications: _____________________________________________________________

Physical and/or Mental Family History (specify what illness and/or difficulty and who)

5. MEDICAL RECORD
Major medical problems: Yes No Which: _________________________________________

Any physical illness (mark with an X)

Asthma Rhinitis Allergies Otitis Bronchospasms
Others which: ______________________________________________________________
Any emotional symptoms (mark with an X)
Anxiety Depression Phobia C Antisocial Obsessive compulsive
Others which: ______________________________________________________________
Surgeries: Yes 0 No 0 Which: _________________________________________________
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Center
6. TREATMENTS
Yea Last check:_______________________________________
Glasses No
h What type: ______________________________________
Orthodontics Yea No
Yeah Last check:_______________________________________
Audiometry No What type: ________________________________
h
Orthopedic treatment Yeah No □ Which: ____________________________________

U.C.
No N Which: ____________________________________
Take some medication Yes No
Other treatments Yeah— □

7. ENGINE
DEVELOPMENT
Specify age at which:
Head control month F
s
-
year He sat month year
s
month syear Path s s
Crawl I leave the teapot
smonth syear month year
I leave the breast Day diaper
smonth syear I leave a rag/doll s s
I let suck
night diaper
smonth — syear Bicycle month year
I ride tricycle > syears s s
s
Roller skates years

Hand preference: C Left-

handed
8. LANGUAGE DEVELOPMENT
Specify the age at which:
Babbling u Vocalize U months
years First sentences C years
months
Responds to name: Yes — No □ Spin in search of No □
Difficulty understanding: Yes □ sound: Yes
Yeah No
Difficulty naming objects: No
Yeah No
Imitates sounds Yeah No
Responds to auditory stimuli Yeah No
Relates events

How he expresses what he wants: ______________________________________________

9. BASIC EVERYDAY ACTIVITIES

How was your diet: Artificial U Maternal Q
Complementary feeding C months 0 years
Type of food: ___________________
Feed change (solids): Yes No n Age: ____________________
Breast suction: C Good C Bad Bottle suction: U Good n Bad
Age: ________________________
Spoon: Yes No Age: ________________________
Cup: Yes No Finger C I Suck 0
Sucking Habits: Yes Objects 0
No
□
 Comprehensive Therapeutic Support
Center
Meal
Enjoy mealtime: Yes • N Because: ______________
I eat alone: Yeah o Because: ______________
Do you reject any type of food: Yes N
Because: _______________________ o
____
Which:
Dream
Age at which I spent the entire night: U
months
Sleep type (mark with an X)
Don't worry Uneasy U Nightmares Q Sleepwalker U
Makes noises when sleeping Bruxism C Talk in sleep 0
Sleep alone: Yes No With who: ___________________
Moves to parents' bed: Yes □ Not C Because:
Control sphincters at night: __
Yeah - Not Q Because:
__

Daily Activities (mark with an X)

Bathroom: Independent Semi-
Dress: Independent independent Dependent
Putting on Semi- Dependent
Independent
shoes: independent Dependent
Hygiene: Independent Semi- □ Dependent
Eat: independent
Semi-
Ye Because ___________________________
He likes caresses: No
ah Because ___________________________
It bothers him to be Ye No
dirty: ah Because ___________________________
Enjoy the bath: Ye No Because ___________________________
He likes to comb his ah
Ye No D No [ ] Why ___________________________
hair: ah
Do you like textures (plasticine, tempera):
Yes
10. SOCIAL BEHAVIOR
No table of contents entries found.

Activities you do at home: How it relates to the father:

Activities you do in the park: How it relates to the mother:

How it relates to the teacher: How he relates to the brothers:

 Comprehensive Therapeutic Support
Center
11. BEHAVIOR
How do you describe your child's character, his/her way of being? ____________________

Does your child express worries and/or fears? Explain ______________________________

What situations have you observed in your child that give you…
Fear _____________________________________________________________________
Happiness ________________________________________________________________
Anger ____________________________________________________________________
Sadness __________________________________________________________________

12. DISCIPLINE
In the house, who is in charge of discipline: ______________________________________
What type of positive consequences are used: ____________________________________
What type of negative consequences are used: ___________________________________
What attitude do you take towards discipline? ____________________________________
What attitude do you take towards authority figures? _______________________________

13. INTERVENTIONS
Occupational Therapy

□ c
No Duration:_______ _______ Professional: _____________
Yes
Speech therapy Yes No Duration:_______ ________ Professional: _____________
Physiotherapy No Duration:_______ ________ Professional: _____________
Psychology •
No — Duration:_______ ________ Professional: _____________
Private classes Yes
□
No Areas: ________________________________________
7

14. ACADEMIC HISTORY

Adequate or early stimulation
Name: ___________________________________________________________________
Admission date: ______________________ Departure date: _________________________
Adaptation process: _________________________________________________________
Observations of the child's performance: ________________________________________

Kindergartens
Name: ___________________________________________________________________
Admission date: ______________________ Departure date: _________________________
Adaptation process: _________________________________________________________
Observations of the child's performance: ________________________________________

Repeated course: Yes 0 No 0

Was in another Garden: Yes n No
□

Comprehensive Therapeutic Support Center

Schools
Name: ___________________________________________________________________
Admission date: ______________________ Departure date: _________________________
Adaptation process: _________________________________________________________
Observations of the child's performance: ________________________________________

Best performance area: ______________________________________________________

Lowest performing area: _____________________________________________________
 Brief description of the reading-writing process: ___________________________________

Current year
Teacher: _________________________________________________________________
Repeated course: Yes • No 0
Were you at another school: Yes No

want to add something _____________________________________________________________

FOR THERAPIST'S USE IN THE INTERVIEW:

I ____________________________________________ identified with Identity Document

No.___________________________ of ____________________, in full use of my faculties
mentalities of free and autonomous taking I declare:

That the treating health professional __________________________________________________,

has explained to me in a comprehensive and sufficient manner the need to carry out the evaluation
and intervention in the areas of Neuropsychology, Psychology, Speech Therapy and/or
Occupational Therapy individually and in groups as part of the treatment of emotional, behavioral
and/or learning problems. ; I have been given every opportunity to ask questions and all of these
have been answered satisfactorily.

That we have been notified that the information provided to the therapist during the process is
subject to professional secrecy and, therefore, cannot be disclosed to third parties without our
express consent. That we have been informed that the therapist is obliged to reveal confidential
information before the appropriate authorities in those situations that could represent a very serious
risk.
 Comprehensive Therapeutic Support
Center

for our son/daughter, third parties or because it was so ordered by a court. In the event that the
judicial authority requires the disclosure of any information, the therapist will be obliged to provide
only that which is relevant to the matter in question, maintaining the confidentiality of any other
information. That we accept that, as parents, we will be informed of the aspects related to the
therapeutic process and its evolution, keeping as confidential the data that we have previously
agreed between us, our child and the therapist.

Father signature Sign of the

mother
Name:
Name:

Sincerely

Catalina Robledo Karen Mesa Juliana de Mier

CC 41,497,322 CC 1,015,434,360 CC 32,746,585
Occupational Therapy Language therapy Child
Neuropsychologist