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DADOS PESSOAIS
.
P r o n t u r io . . . . . . . . . . . . . . . . . / . . . . . . . .
)S (
)S (
)N
)M (
) F Naturalidade: __________________________________
End. _______________________________________________________________________________________
Bairro:____________________________ Cidade:______________________ CEP _________________________
Fones para contato:____________________________________________________________________________
Escola:_______________________________________________________________Srie que cursa: _________
End._______________________________________________________________________________________
Fone:_____________________________________________Contato:___________________________________
Prof_______________________________________ Horrio__________________________________________
Pai :________________________________________________________________________ Idade :__________
Estudou at_____________________________ Teve Dificuldade? (
)S ( )N
Se formou? (
)S ( )N
Profisso ____________________________________________________________________________________
Me :_______________________________________________________________________ Idade :_________
Estudou at_____________________________ Teve Dificuldade? (
)S ( )N
Se formou? (
)S ( )N
Profisso ____________________________________________________________________________________
Irmos: ( nome e idade )
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Esquema Familiar:____________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
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Pgina 1
QUEIXA
Na escola ___________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Indicado por_________________________________________________________________________________
Em que acha que o profissional poder ajud-lo(a)?
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
HIST RIA DE VID A
CONCEPO :
Filho(a) desejado(a) ( ) sim ( )no
( )no
( )no
Pgina 2
ELIMINAO
Com que idade parou de usar fraldas? _____________________________________________________________
Como foi a passagem para o troninho (segurava? molhava a roupa? brincava e saia correndo era repreendido?
chorava?) ___________________________________________________________________________________
___________________________________________________________________________________________
Como eram as fezes ?
( )lquida
( )pastosa
( )ressecada
( )normal
EVOLUO PSICOMOTORA
Ficou no cercadinho ( )sim ( )no
( )no
( )no
( )no
)sim (
Anda de patins? (
)sim (
Anda a cavalo ? (
)sim
)no
Nada ? (
)no
(
)sim (
)no
agitado(a)? ( )sim (
)no
Sobe em rvores ? (
)sim (
)sim (
)no
)no
)no
FALA
Com que idade comeou a falar ?_____________________Com quem falava mais ?______________________
Falava(m) para ele(a) repetir ? (
)sim (
)no
Pgina 3
Quais? _______________________________________________________
) sim
)no
) sim
)no
) sim (
)no
D um exemplo:______________________________________________________________________________
____________________________________________________________________________________________
Voc entende o que ele(a) conta ? (
Tem comeo, meio e fim ? (
) sim (
) sim
)no
)no
SONO
agitado? ( )sim ( )no
( )no
H I S T R IAC L N I C A:
Ocorreram:
Bronquite ? (
) sim
Viroses infantis? (
)no
) sim (
Alergia? (
)no
Internaes ? (
) sim (
) sim
)no
(
)no
Asma? (
) sim (
)no
Cirurgias ? (
) sim (
)no
) sim (
)no
Outras doenas:
Tratamentos realizados (fonoaudilogo, psiclogo....)
Qual? ______________________________________________________________________________________
Problemas de viso? ( )sim ( )no
Audio?
) sim (
)no
Pgina 4
) sim
Revistas ? livros ? (
) sim
)no
)no
jogos? (
) sim (
)no
brinquedos eletrnicos ? (
) sim (
)no
)no
dana ? ( )sim (
)no
esporte ? ( )sim (
)no
Qual?_______________________________________________________________________________________
SITUAES NEGATIVAS VIVENCIADAS PELA CRIANA (atravs de alteraes familiares)
nascimento de irmos (
) sim (
) sim
)no
mudanas(
) sim (
)no
De quem? ___________________________________________________________
(
)no
separaes (
) sim (
)no
H I S T R I A D A F A M I LI AA M P LI AD A
Famlia: Passado, Presente, Interferncias, Ligaes, Quadros Patolgicos
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Forma de Disciplina:
____________________________________________________________________________________________
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Pgina 5
Quem? _____________________________________
( )no
a me ( )sim ( )no
os irmos ( )sim
( )no
Pgina 6
( )no
____________________________________________________________________________________________
Houve problema com professor (es) ? ( )sim
Qual ?
( )no
____________________________________________________________________________________
( )no
( )no
Encaminhamento:
(
) psiclogo
( ) neurologista
( ) fonoaudiologista
) oftalmologista
( ) pediatra
) outros: ____________________________________________________________________
) otorrino
So Paulo, _____de_____________________________de200___.
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Pgina 8