Atesto, para os devidos fins, que

o(a)candidato(a)_________________________________
_________________________________________________________________________
_
portador do documento de identificao n
_____________________________________, examinado por mim nesta data,
apresenta as seguintes condies psquicas:
conscincia:_____________________________________________________________
__
_________________________________________________________________________;
orientao:______________________________________________________________
__
_________________________________________________________________________;
-ateno:________
__________________________________________________________
_________________________________________________________________________;
pensamento
(curso,
forma
e
contedo):
________________________________________
_________________________________________________________________________;
memria:________________________________________________________________
_
_________________________________________________________________________;
-senso
percepo:
_________________________________________________________;
_________________________________________________________________________;
-humor/afeto:____________
__________________________________________________
_________________________________________________________________________;
cognio/inteligncia____________________________________________________
___
_________________________________________________________________________;
-capacidade de tirocnio e juzo
crtico:__________________________________________
_________________________________________________________________________;
linguagem:______________________________________________________________
__
_________________________________________________________________________;
-uso ou no de medicamentos psicotrpicos
(psicofrmacos):________________________
_________________________________________________________________________.
Concluso:______________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_______________________________.

(Fortaleza/Ce), ______ de_________________ de 201_.

Atenciosamente,
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