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com/doc/20136090/Anamnese-MODELOS-DE-FICHAS-PARA-
AVALIACAO
ANAMNESE PSICOPEDAGÓGICA
DADOS PESSOAIS
Prontuário................./.........
Nome:________________________________________
____________________________idade:_________ anos Tem apelido? ( ) S ( ) N
Qual?___________ ____________ ________________ Ele(a) gosta? ( ) S ( ) N Por
que tem esse apelido?
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Nascimento_____/_____/_____ Sexo ( ) M ( ) F Naturalidade:_____
_____________________________
End.______________________________________________________
_________________________________ Bairro:____________________________
Cidade:______________________ CEP_________________________ Fones para
contato:_____________________________________________________________________
_Escola:_______________________________________________________________Série
que cursa:_________
End.________________________________________________________________________
_______________
Fone:_____________________________________________Contato:__________________
_________________ Profª_______________________________________
Horário__________________________________________
Pai :________________________________________________________________________
Idade :__________
Se formou? ( ) S ( ) N
Profissão____________________________________________________________________
________________
Mãe :_______________________________________________________________________
Idade :_________
Se formou? ( ) S ( ) N
Profissão____________________________________________________________________
________________
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Esquema
Familiar:____________________________________________________________________
_____________________________________________________________________________
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__
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QUEIXA
Na escola___________
______________________________________________________________ __________
_____________________________________________________________________________
_______________
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_______________
_____________________________________________________________________________
_______________ Indicado
por_________________________________________________________________________
________ Em que acha que o profissional poderá ajudá-lo(a)?
_____________________________________________________________________________
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HISTÓRIA DE VIDA
CONCEPÇÃO :
ELIMINAÇÃO
chorava?)___________________________________________________________________
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EVOLUÇÃO PSICOMOTORA
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Hoje
Hoje:
SONO
HISTÓRIA CLíNICA:
Ocorreram: