This document contains sections for collecting a student's personal information, medical and family history, educational background, parent expectations and support, results of psychological assessments, a presumed diagnosis, recommended psychological treatment, and additional notes. Specifically, it requests details on the student's name, age, birthdate, school, grades, address, informant contact information. It also includes spaces to describe the student's prenatal history, birth, feeding, development of motor skills, illnesses, and schooling progression. Finally, it outlines sections for parent feedback and perspectives on their child's strengths and needs.

1. HISTORIA PSICOPEDAGÓGICA
I. DATOS GENERALES
Nombre y apellidos: __________________________________________________Edad: _______________
Fecha de nacimiento: ________ Lugar de nacimiento: _____________ Procedencia: _________________
Centro educativo: __________________________ Grado: ____________ Sección: ___________________
Padre o apoderado: _______________________________ Dirección: ______________________________
Teléfono: __________________ Informante: ________________________________ Fecha: ____________
Tutor: __________________________________
II. ANTECEDENTES
2.1. Historia Prenatal
- Embarazo: __________________________________________________________________________
- Parto: ______________________________________________________________________________
- Accidentes durante el Parto: ____________________________________________________________
- Enfermedades. _______________________________________________________________________
2.2. Historia Natal
- Lactancia materna: ______________ biberón: ___________ hasta que edad: __________________
- Control de esfínteres
- Vesicales: diurno ____________________ nocturnos________________________
- Anales : diurno ____________________ nocturnos________________________
- Habló: ______________ comió: ________________ aprendió a vestirse
solo(a):____________________
- Aprendió a comer solo (a): ________________________
- Enfermedades: ________________________ recibió tratamiento: _____________ edad: ____________
2.3. Historia Escolar
Nivel Centro Educativo Proceso de adaptación
Inicial
Prima
ria
1°
2°
3°
4°
5°
6°
Secun
daria
1°
2°
3°
4°
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2. 5°
2.4. Historia Familiar
Nombres Edad Ocupación Nivel de
instrucción
Relación con el
evaluado
Padre
Madre
Hermanos
Tíos
Abuelos
maternos
Abuelos
paternos
Otros
III. ¿QUÉ LE GUSTARIA QUE SE REFUERZE MAS EN EL CENTRO EDUCATIVO PARA AYUDAR A SU
HIJO(A)?
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IV. ¿QUÉ EXPECTATIVAS TIENE SOBRE SU HIJO(A)?
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V. ¿CÓMO LE GUSTARIA QUE FUERA SU HIJO(A)?
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VI. ¿DE QUE FORMA APOYARÍA USTED A SU HIJO(A) ANTE SU DIFICULTAD?
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VII. INDICADORES DE LAS PRUEBAS ADMINISTRADAS
Inteligencia:
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3. _________________________________________________________________________________________
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Organicidad:
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Emociones:
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Otros:
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VIII. PRESUNCION DIAGNOSTICA
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IX. TRATAMIENTO PSICOLOGICO
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X. OBSERVACIONES ADICIONALES
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4. Lima, ___ de _________ de 20__
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