PREFEITURA MUNICIPAL DE CAMPO GRANDE

ESTADO DE MATO GROSSO DO SUL

SAS - SECRETARIA MUNICIPAL DE POLTICAS E AES SOCIAIS E CIDADANIA
DIVISO DE PROTEO SOCIAL BSICA

UNIDADE:CRAS VILA GAUCHA

N. do NIS Responsvel Familiar:_____________________
( )Acompanhamento

( )Prioritrio

( ) Sigas

FORMA DE INGRESSO NA UNIDADE:

( ) Demanda Espontnea
( ) Busca Ativa do CRAS
( ) Encaminhado DIBE/DPB/SAS
( ) Encaminhado CREAS/Conselho Tutelar
( ) Encaminhado UBS/Sade
( ) Encaminhado Escola/Educao
( ) Encaminhado Poder Judicirio/Defensoria Pblica/Tribunal Regional Federal
( ) Encaminhado Outras Polticas ___________________________________

I - IDENTIFICAO:
Nome: __________________________________________________________ Idade: ______________D.N: _________________________
Filiao: pai: ___________________________________________me: _______________________________________________________
Endereo: _________________________________________________________N: ___________ Complemento: ____________________
Bairro: __________________________P. Referncia: _________________________ CEP: _____________ Fone: ____________________
Regio: ( ) Central ( ) Segredo ( ) Prosa ( ) Bandeira ( ) Anhanduizinho ( ) Lagoa ( ) Imbirussu Zona: ( ) Urbana ( ) Rural
Estado Civil: ___________________Naturalidade: _________________________________________Grau de Instruo:________________
Documentos Pessoais: RG________________ emisso ______________ rgo_________ CPF __________________________________
Carteira Profissional ___________ srie ________ emisso _________T. Eleitor _______________________Zona______ Seo________
Unidade de Sade Referncia: ________________________________________ N Pronturio: ________________________________
II Benefcios
(

)Bolsa Famlia (

R$ __________

)PETI

)BPC Idoso (

)BPC PPD (

)Passe Social (

R$ _______ R$ _________ R$ _________ R$ _________

)Frente Emergencial (

R$ _______________

)Vale Renda (
R$ ____________

) Emha

III - COMPOSIO FAMILIAR

Informe o nome de todas as pessoas que moram na residncia (comeando pelo Titular).
N.

NIS

Nome Completo
(No abreviar)

Raa

Estado

Data

Civil

Nasc.

10

IV FORMAO/ESCOLARIDADE
Transfira para este quadro todos os moradores do quadro III na mesma ordem.

Grau
De
parentes
co

Situao

Profisso

Renda

Ocupaci
onal

Aes
Inseridas

Alfabetizado

N.

Estuda

Nvel e

atualmente

srie atual

Primeiro Nome

ou
Sim

No

Sim

No

concludo
(NC)

1
2
3
4
5
6
7
8
9
10

Cursos
Formao Profissional/Escola que estuda

V CONDIES DE SADE:
Transfira para este quadro os moradores que apresentam problemas de sade.
inscrita
Tem carteira Vacinao est
Fez
N

Primeiro Nome

--1
2
3
4
5
6
7
8
9
10

------------------------

no SUS?
SIM

NO

de
Vacinao?
SIM NO

DC Doena: 1) Anemia 2) Cardaca 3) Depresso

atualizada?

preventivo de

Deficincias

Doenas

SIM

cncer?
SIM NO

-----------------------

------------------

NO

4) Hipo/Hipertenso 5) Epilepsia 6) Diabetes 7) Respiratrio 8) Circulatrio 9) Renal 10) Desidratao 11)

Desnutrio 12) Sarampo 13) Hepatite 14) Ttano 15) Catapora 16) Caxumba 17) Rubola 18) Coqueluche 19) Vermes 20) Doenas dos ossos e articulaes 21) Cncer
22) DST 23) HIV 24) Pele 25) Neurolgica 26) Outra: _______________
DF Deficincia: 1) Auditiva 2)Visual 3) Mental 4) Fsica 5) Mltiplas 6) Outra: ________________

Usurio Substncia Psicoativa:

Fuma: (

) Sim (

Bebida Alcolica: (

) No Quem? ________________________________Tempo: __________________

) Sim (

Dependente Qumico: (

) No Quem? ________________________Tempo:

) Sim (

Existem gestantes na casa? (

) No Quem? ____________________Tempo: __________________

)Sim (

)No

Quem?_______________________Tempo Gestao:_____________

Existem crianas de zero (0) a seis (6) anos atendidas por desnutrio?( ) Sim, quantas? ________ ( ) No
Existe idoso com mais de 65 anos incapazes de prover o prprio sustento?( ) Sim, quantos? ________ ( ) No

VI SITUAO HABITACIONAL
Condies de Moradia: (

)Prpria (

)Alugada: Valor; ______________(

Financiada: ValorR$ ________________ (

)Cedida por: ___________________(

)Co-habitada (

)Invadida

Tempo de Residncia: ______________ N de cmodos: ___________

Tipo de Construo: (
Rebocada: (
Forrada: (

)Sim
)Sim

Possui Banheiro (

) Alvenaria (
(

)No
)No

) Madeira (
Pintada: (

) Mista (
)Sim

Possui Piso: (

) ou Sanitrio (

)Sim

) Lona (

(Compensado

)No
(

)No

Possui quais mveis:

_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Conservados: (

)Sim

)No

VII - INFRA-ESTRUTURA/DESPESAS:
1 gua: ( ) Encanada ( ) Comunitria ( ) Poo Artesiano (
) Clandestina. Valor: R$ _____________
2 Esgoto: (
) Fossa Sptica/Rudimentar ( ) Crrego (
) Rede (Tratado).
3 Energia Eltrica: ( ) Prpria ( ) Comunitria ( ) Ligao Clandestina. Valor: R$ ______________
4 Lixo: ( ) Coletado (
) Queimado (
) Enterrado ( ) Reciclado ( ) Outros:
5 Alimentao ( ) Prpria R$ ________________ ( ) Doao. Quem? ____________________
6 Possui Asfalto ( )Sim (
)No
7 Gs de cozinha ( ) Prpria R$ _____________ ( ) Doao. Quem? ____________________
8 Medicamentos ( ) Prpria R$ ______________ ( ) Doao. Quem? ____________________
9 Outros gastos ________________________________________________________ R$ ___________
RENDA PER CAPTA: _________________

TOTAL DE DESPESAS: ________________

VIII - Histrico Familiar e Social:

_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________

IX - Acompanhamento e Orientao:
Data
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /

Assunto

Tcnico

______________________________________________

SIGAS

____________________________________________

Assinatura do entrevistado(a)

Nome do entrevistador(a)
DATA _____/_____/_____