Escolar Documentos
Profissional Documentos
Cultura Documentos
I.
DATOS GENERALES
Nombre y Apellidos:
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_____
Accidentes ______
Caminar dormido ______
Fiebres _____
Convulsiones _____
Consumo de drogas
_____
Si_____
No _____
Si respondi
III.
INFORMACION FAMILIAR:
Casados_____
Divorciados _____
Si contest lo
separacin: ______________________________________________________________
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Cuntos hermanos tiene? _____
mujeres? _____
cuantas son
nuclear?_____________
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Si _____ No _____
Si su
Si _____ No _____
usted?
Si _____ No _____
Cuntos? ______
Describa las
satisfacciones
vividas
en su rol de madre o padre:
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Describa los mayores problemas que ha enfrentado en su rol de madre o padre:
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________________________________________________________________________
________________________________________________________________________
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Existen antecedentes de alcoholismo en su familia? Si _____ No _____
Si respondi
________________________________________________________________________
Se han presentado casos de depresin u otra enfermedad mental en su familia?
Si _____ No _____ cules?_________________________________________________
________________________________________________________________________
________________________________________________________________________
Cunteme una historia feliz o divertida vivida en familia:
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________________________________________________________________________
________________________________________________________________________
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Cunteme una historia feliz o divertida vivida con otras personas:
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Firma: _______________________________________