Você está na página 1de 4

ANAMNESE COM OS PAIS

CLIENTE DADOS PESSOAIS:


Nome:__________________________________________________________
Idade:_______________________________ D.N:_____/_____ /____________
Endereo:_______________________________________________________
_______________________________________________________________
Fone(s):________________________________________________________
_
Me:______________________________________________Idade:________
Profisso:__________________________Escolaridade:__________________
Pai:_______________________________________________Idade:________
Profisso:__________________________Escolaridade:__________________
Irmos:_________________________________________________________
_______________________________________________________________
Com quem mora?_________________________________________________
Casa ou Apartamento?_____________________________________________
Descreva de forma resumida a rotina familiar do cliente:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
DADOS ESCOLARES:
Escola:_________________________________________________________
Endereo:_______________________________________________________
_______________________________________________________________
Fones:__________________________________________________________
Desde
___________________________________________________

quando?

Professora:______________________________________________________
Outros:_________________________________________________________

QUEIXA.
Comportamentos-problema que motivaram a procura descrio
atual:___________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Dimenso do comportamento-problema:
Frequncia:______________________________________________________
_______________________________________________________________
_______________________________________________________________
Intensidade:_____________________________________________________
_______________________________________________________________
_______________________________________________________________
Durao:________________________________________________________
_______________________________________________________________
_______________________________________________________________
Circunstncias nas quais ocorre:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Histrico do comportamento-problema.
Quando iniciou:__________________________________________________
Como Iniciou:____________________________________________________
Como
se
desenvolveu
at
apresentar-se
da
forma
atual?
_______________________________________________________________
_______________________________________________________________
__________________________________________________________
O que ocorre imediatamente antes da ocorrncia do problema?
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

O que ocorre imediatamente depois da ocorrncia do problema?


_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Quais as conseqncias gerais do problema?
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Quais as conseqncias quando o comportamento-problema no ocorre?
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
O que as outras pessoas dizem sobre o problema?
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
O que voc pensa sobre o problema?
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Houve tratamentos anteriores ou tentativa de resolver o problema mesmo
informal?
_______________________________________________________________
_______________________________________________________________
Condies gerais do cliente:
Doenas:________________________________________________________
_______________________________________________________________
Alimentao:_____________________________________________________
_______________________________________________________________
Independncia:___________________________________________________
_______________________________________________________________