Entrevista General Terapia Ocupacional

ENTREVISTA TERAPIA OCUPACIONAL ANTECEDENTES PERSONALES Nombre completo ___________________________________________________ Edad _____________________________________________________________ Estado Civil ________________________________________________________ Ocupación _________________________________________________________ Entrevistador y fecha entrevista: ________________________________________ ANTECEDENTES FAMILIARES Padre_____________________________________________________________ Madre ____________________________________________________________ Con quién vive______________________________________________________ __________________________________________________________________ Relación con grupo familiar____________________________________________ __________________________________________________________________ __________________________________________________________________ Relación entre los padres _____________________________________________ __________________________________________________________________ Genograma

ANTECEDENTES PSICOSOCIALES Situación socioeconómica ____________________________________________ Situación legal ______________________________________________________ Ocupación padre e ingreso ____________________________________________ Ocupación madre e ingreso____________________________________________ Ocupación familiares e ingreso _________________________________________ Factores de Riesgo VIF ( ) MI ( ) AS ( ) OH ( ) Drog ( ) Abandono ( ) Vagancia ( ) Otro ______________________ Descripción________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________

HISTORIA CLÍNICA Periodo de Gestación y Nacimiento Embarazo de la madre _______________________________________________ Estado de ánimo ____________________________________________________ Actitud de la pareja __________________________________________________ Problemas en el embarazo ____________________________________________ Periodo gestación ___________________________________________________ Tipo de parto _______________________________________________________ Problemas en el nacimiento ___________________________________________ Lactancia materna __________________________________________________ Vínculo con la madre ________________________________________________ Vínculo con el padre _________________________________________________ Otro ______________________________________________________________ __________________________________________________________________ __________________________________________________________________ Desarrollo Psicomotor Control de la cabeza _________________________________________________ Posición sentado ____________________________________________________ Gateo ____________________________________________________________ Marcha ___________________________________________________________ Control esfínter _____________________________________________________ Otro ______________________________________________________________ Anamnesis Dg actual__________________________________________________________ __________________________________________________________________ Inicio______________________________________________________________ __________________________________________________________________ Desarrollo _________________________________________________________ __________________________________________________________________ __________________________________________________________________ Tratantes anteriores _________________________________________________ __________________________________________________________________ Tratamiento actual __________________________________________________ __________________________________________________________________ Fármacos (nombre, gramaje, dosis por día) __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________

DESEMPEÑO OCUPACIONAL Rutina diaria Semana___________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Fines de Semana ___________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Roles que desempeña __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Desempeño ABVD Higiene menor ______________________________________________________ Higiene mayor ______________________________________________________ Control esfínter _____________________________________________________ Uso del baño _______________________________________________________ Vestimenta_________________________________________________________ Comer ____________________________________________________________ Traslado___________________________________________________________ Descripción ________________________________________________________ __________________________________________________________________ Desempeño AIVD Preparación alimentos _______________________________________________ Medicación ________________________________________________________ Uso del teléfono ____________________________________________________ Cuidado de la casa __________________________________________________ Compras __________________________________________________________ Uso transporte _____________________________________________________ Manejo dinero ______________________________________________________ Descripción ________________________________________________________ __________________________________________________________________

Desempeño Descanso y Sueño __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Desempeño Escolar Curso y colegio ____________________________________________________ Historia escolar ____________________________________________________ __________________________________________________________________ Rendimiento _______________________________________________________ __________________________________________________________________ Conducta __________________________________________________________ __________________________________________________________________ Relación con compañeros ____________________________________________ __________________________________________________________________ Desempeño Juego Tipo de juego ______________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Compañeros de Juego _______________________________________________ __________________________________________________________________ Desempeño Ocio y Tiempo libre __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Actividades y roles de interés __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Desempeño Participación Social Relación con grupos sociales __________________________________________ __________________________________________________________________ __________________________________________________________________ Relación con pares __________________________________________________ __________________________________________________________________

Redes de apoyo Familia y amigos ____________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Instituciones________________________________________________________ __________________________________________________________________ __________________________________________________________________ Mapa de red / Ecomapa

Dificultades el desempeño ocupacional __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Expectativas de Intervención __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ IMPRESIÓN GENERAL Conducta manifestada _______________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Contacto visual _____________________________________________________ __________________________________________________________________ Tipo de comunicación ________________________________________________

__________________________________________________________________ Conexión con la realidad _____________________________________________ __________________________________________________________________ Postura corporal ____________________________________________________ __________________________________________________________________ Arreglo personal ____________________________________________________ __________________________________________________________________

Comentarios __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________

Impresión Diagnóstica __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________