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Fonoaudiologa Ficha FA: _________N Historia; ________

FICHA FONOAUDIOLOGICA

I. ANTECEDENTES PERSONALES:

Nombre:____________________________________________________Fecha:_______________________Fecha de Nacimiento:____________________________Edad:________ Telfono (s):___________________Domicilio: _______________________________________________________________________________Escolaridad: ___________________________________ Profesin:____________ Nacionalidad: __________Estado Civil:________________________________ ___ Hijos: ____________________________________Idiomas que Habla: _______________________________________________ Lateralidad: ______________Hospitalizado: __________________________________ Ambulatorio: ______________________________Trastornos FA Premrbidos:_________________________________________________________________

________________________________________________________________________________________

II. ANTECEDENTES PSQUICOS:

Premrbidos:_____________________________________________________________________________________________________________________________________________________________________

Postmrbidos: ____________________________________________________________________________________________________________________________________________________________________

III. ANTECEDENTES SOCIOECONMICOS:

(situacin laboral, previsin):_________________________________________________________________________________________________________________________________________________________

IV. OTROS ANTECEDENTES:

Informante: _____________________ Referido por: ____________________ Examinador: _______________Observaciones: ___________________________________________________________________________

________________________________________________________________________________________

V. ANTECEDENTES CLINICOS:

Historia clnica (fecha de inicio): ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Diagnsticos:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Otros antecedentes:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________