Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
I. ANTECEDENTES PERSONALES
Nombre: ________________________________________________________________________
Edad : __________ Fecha de Nacimiento: __________________________________
Cedula de identidad: ___________________ N de ficha: _______________________________
Direccin: ______________________________ _________________________________________
Telfono de contacto: ____________________________Previsin de Salud: __________________
RND: SI ___ NO ___ En Trmite___
Nombre de la persona responsable:___________________________________________________
Telfono: ________________________ Email: _________________________________________
Nombre del cuidador asignado: ______________________________________________________
II. ANTECEDENTES DE SALUD
________________________________________________________________________________
________________________________________________________________________________
Vivienda:
Casa propia: SI / NO Allegado: SI / NO N de pisos (niveles): ___ Sector: URBANO / RURAL
Adaptaciones ambientales: SI / NO (especificar cules):
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Servicios bsicos:
Agua potable: SI / NO Luz: SI / NO Alcantarillado: SI / NO Calefn: SI / NO
Cocina: Si/No Gas/Lea
Otros servicios:
Internet ___ telefona fija/mvil ___ Asesora de hogar ___ Movilizacin particular ___
Antecedentes educacionales:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Experiencia laboral: (trabajos, capacitaciones, voluntariados, aos de experiencia, etc.)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Tiempo de ocio y esparcimiento: (Actividades e intereses):
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Rutina
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
_______________________________________________________________________________
V. ANTECEDENTES DE LA FAMILIA/ CUIDADOR
Genograma
Hitos:___________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Mapa de redes:
Observaciones:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Profunda
Temperatura
Estereognosia
Propiocepcin
IV. OBJETIVOS DE LA INTERVENCIN
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
B.- OBJETIVOS A TRABAJAR EN LA INTERVENCIN
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
C.- ACCIONES SEGN PRESTADOR
Familia
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Diciembre
Lu. Ma. Mi. Ju. Vi. Sa . Do.
1
2 3 4 5 6 7 8
9 10 11 12 13 14 15
16 17 18 19 20 21 22
23 24 25 26 27 28 29
30 31