ENTREVISTA COM ADULTOS

HORÁRIO - Feira – Das hs às hs

IDENTIFICAÇÃO

NOME:
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NACIONALIDADE: ___________________________

NATURALIDADE: ____________________________

SEXO: ___________________________

IDADE: _________Anos

ESTADO CIVIL: ________________________________

GRAU DE INSTRUÇÃO: _____________________________________

PROFISSÃO OU OCUPAÇÃO: ________________________________

ENDEREÇO ATUAL: ________________________________________

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BAIRRO:
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TELEFONE: ___________________CELULAR:
___________________

RESIDÊNCIA PRÓPRIA: _______________________

N° DE CÔMODOS: __________________________________________

CONDUÇÃO DA FAMÍLIA: ___________________________________

SE TEM EMPREGADOS E FACILIDADES NA LIMPEZA E

TRABALHOS DOMÉSTICOS: ________________________________
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 FAMÍLIA

PAIS:VIVOS OU FALECIDOS:________________________________

TIPO DE UNIÃO (LEGÌTIMA OU ILEGÌTIMA, DIVORCIADOS,

ETC.):
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GRAU DE INSTRUÇÃO:
PAI:________________________________________________________
MÃE:_______________________________________________________

PROFISSÃO OU OCUPAÇÃO:
PAI:________________________________________________________
MÃE:_______________________________________________________

NACIONALIDADE:
PAI:________________________________________________________
MÃE:_______________________________________________________

IRMÃOS:

NÚMERO:______________________________

IDADE:_____________________________________________________

SEXO:______________________________________________________

VIVOS OU FALECIDOS:______________________________________
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Na Constelação Familiar é

ESPOSO(A) VIVO OU FALECIDO:_____________________________

IDADE:____________________

GRAU DE INSTRUÇÃO:______________________________________

OCUPAÇÃO OU PROFISSÃO:_________________________________
NACIONALIDADE:__________________________________________
NATURALIDADE:___________________________________________

TIPO DE UNIÃO:____________________________________________

FILHOS:

NÚMERO:__________________________________________________

IDADE:_____________________________________________________

SEXO:______________________________________________________

VIVOS OU FALECIDOS:______________________________________
MOTIVO DA CONSULTA
- Deixar falar livremente
- O que está acontecendo com senhor(a)?
-Desde quando se sente assim?
- Como começou?
- Teve melhoras ou pioras?
Quando o motivo da consulta é orientação profissional ou educacional,
inclui-se problemas relativos a : Ambições; Interesses; Dificuldades,
etc.
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INFÂNCIA E ADOLESCÊNCIA

→Recordações e impressões (relatar as que mais ficaram gravadas)

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→Ambiente do Lar (Inter-relações, disciplinas, etc.)

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→Distúrbios do Comportamento, Problemas de Alimentação, de Sono,

de linguagem, dificuldades de relacionamento, mentiras, fugas, medos.
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VIDA ESCOLAR

→ Histórico- Idade em que começou a freqüentar a escola, mudanças

de escola, reprovações e causas, dificuldades, preferências,
relacionamento com os professores, com os colegas, participação em
trabalhos de grupo, participação de atividades extracurriculares
(grêmio, centro de estudos,etc...)
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VIDA PROFISSIONAL

→ Emprego atual, salário (evitar perguntas diretas, indagar se está

satisfeito ou não), ambições, relacionamento com superiores, com os
colegas, atitudes frente às exigências de horário, empregos anteriores,
motivo de mudanças, etc.
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HÁBITOS E ROTINA DIÁRIA

→Alimentação – Horário, Apetite, Preferências

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→Vestuário – importância dada
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→Descanso – problemas de sono, horário

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→Sonhos- temas freqüentes

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→Vícios
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VIDA SOCIAL

→ Programas costumeiros, freqüência com que recebe ou faz visitas

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→Estudo – maneira de estudar, horário

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GOSTOS E INTERESSES

→Maneira de passar as horas de lazer, distrações preferidas, leituras,

filmes preferidos, pratica de esportes, etc.
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VIDA SEXUAL

→Namoros, noivado, vida conjugal, relações extraconjugais

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CONHECIMENTOS SEXUAIS

→Como foram obtidos, quando, preocupações, iniciação sexual

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MASTURBAÇÃO

→Idade em que iniciou, freqüência, atitude frente ao fato

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DOENÇAS VENÉREAS
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OBS: Se feminino deve-se perguntar a respeito da menstruação, idade

em que ficou menstruada, como reagiu, regularidade, cólicas, etc.
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DOENÇAS E ACIDENTES

→ Quando foram e conseqüências

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→ Doenças – Cefaléia, Alergias, Transtornos Digestivos, Respiratórios
ou Cardíacos, Ataques, Desmaios.
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→ Pesquisar inicio, evolução, tratamentos feitos

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AMBIENTE SÓCIO FAMILIAR

→Estrutura do Lar (pessoas com quem vive)

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→Inter-relações
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→Tipo de residência
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ANTECEDENTES MÒRBIDOS

→ Pesquisar em relação aos familiares (Pais, Irmãos, Tios, a presença

de doenças tais como : Alergias, Ataques, Distúrbios Mentais,
Deficiências Sensoriais de Linguagem, etc...).
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Se algum desses familiares faleceu indagar a causa e a idade de

falecimento.
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IMPRESSÕES DA PSICÒLOGA

→Anotar as reações da pessoa frente às perguntas feitas, a maneira de

se relacionar com o entrevistador e a atitude geral durante a entrevista.
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DATA DA ENTREVISTA: _____________________________

ENTREVISTA COM ADOLESCENTES

 HORÁRIO - Feira – Das hs às hs

IDENTIFICAÇÃO

NOME:_____________________________________________________
____________________________________________________________

NACIONALIDADE:___________________________

NATURALIDADE:____________________________

SEXO:___________________________

DATA DE NASC. :__________________IDADE:_________Anos

ESTADO CIVIL:________________________________

GRAU DE INSTRUÇÃO:______________________________________

PROFISSÃO OU OCUPAÇÃO:_________________________________

ENDEREÇO ATUAL:_________________________________________
____________________________________________________________

BAIRRO:____________________________________________________

TELEFONE:___________________CELULAR:___________________

RESIDÊNCIA PRÓPRIA:_______________________

N° DE CÔMODOS:___________________________________________

CONDUÇÃO DA FAMÍLIA:___________________________________

SE TEM EMPREGADOS E FACILIDADES NA LIMPEZA E

TRABALHOS DOMÉSTICOS:_________________________________
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ESCOLA QUE FREQUENTA:_________________________________
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PAIS VIVOS:________________________________________________
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IDADE PAI:________________SAÚDE:__________________________
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ESTADO CIVIL:_____________________________________________
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IDADE MÃE:________________SAÚDE:_________________________
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ESTADO CIVIL:_____________________________________________
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CONSTELAÇÂO FAMILIAR:_________________________________

IRMÃOS:

NÚMERO:______________________________

IDADE:_____________________________________________________

SEXO:______________________________________________________

ESCOLARIDADE:___________________________________________
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CONTRIBUIÇÃO NO ORÇAMENTO DOMÈSTICO:_____________

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QUANTAS PESSOAS VIVEM EM CASA:_______________________

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SAÚDE:_____________________________________________________
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ESTUDOS ATIVIDADES DE GRUPO INTERESSES

O QUE VOCÊ ACHA DA SUA ESCOLA?

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ENSINO_____________________________________________________
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PROFESSORES______________________________________________
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COLEGAS__________________________________________________
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ASPECTOS GERAIS__________________________________________
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COMO VOCÊ SE SENTE NA ESCOLA_________________________

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COMO TEM SIDO SEU APROVEITAMENTO?__________________

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FACILIDADES E DIFICULDADES (Repetições, aulas particulares)
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PREFERÊNCIAS E AVERSÕES________________________________
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MÉTODO DE ESTUDO (Horário e forma) _______________________

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QUE ESCOLA FREQUENTOU?________________________________

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MOTIVOS DA MUDANÇA____________________________________
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VOCÊ TEM OUTRAS AULAS? (Línguas, judô, violão, pintura, etc....)

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PARTICIPA DE ALGUM GRUPO FORA DA ESCOLA? (Time de

futebol, bandeirantismo, escotismo, teatro, etc...)
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COMO VOCÊ GOSTA DE SE OCUPAR EM CASA?______________

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LEITURA (Revistas/livros) ____________________________________

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TELEVISÃO (Programas preferidos) ____________________________

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OUTROS (Aeromodelismo, coleções, etc.) ________________________

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COMO SÃO OS SEUS FINS DE SEMANA EM GERAL?___________

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O QUE COSTUMA FAZER EM ÈPOCA DE FÉRIAS?_____________

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RELACIONAMENTO FAMILIAR

COMO SÂO SEUS IRMÃOS?__________________________________

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COMO SE DÁ COM ELES?___________________________________
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O QUE ACHA DELES?_______________________________________

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COMO É SEU PAI?___________________________________________

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O QUE VOCÊ ACHA DELE?__________________________________

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O QUE ELE FAZ?____________________________________________

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O QUE VOCÊ ACHA DISSO?__________________________________

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COMO É SUA MÃE?_________________________________________

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O QUE VOCÊ ACHA DELA?__________________________________

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O QUE ELA FAZ?____________________________________________

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O QUE VOCÊ ACHA DISSO?__________________________________

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COM QUAL DOS MEMBROS DA FAMÍLIA VOCÊ SE DÀ

MELHOR?__________________________________________________
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VOCÊ DISCUTE PROBLEMAS DA ESCOLA EM CASA?_________

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RELACIONAMENTO FORA DE CASA

ONDE VOCÊ TEM AMIGOS?_________________________________

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ONDE SE ENCONTRA COM ELES?____________________________

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QUE FAZEM JUNTOS?_______________________________________

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TEM ALGUM AMIGO MAIS ÌNTIMO?_________________________

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QUAL O AMIGO QUE MAIS ADMIRA?________________________

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POR QUÊ?__________________________________________________
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O QUE SEUS PAIS ACHAM DE SEUS AMIGOS?________________

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NAMORADO (A) TEM?_______________________________________

QUANTO TEMPO?___________________________________________
RELACIONAMENTO SEXUAL

VIDA SEXUAL ATIVA OU NÃO?______________________________

COMO OBTEVE AS PRIMEIRAS INFORMAÇÕES /VIRGINDADE.

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MASTURBAÇÃO/ ACONTECE OU NÃO________________________

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MENSTRUAÇÃO____________________________________________
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ACEITAÇÃO DE SI MESMO E REAÇÕES EMOCIONAIS

VOCÊ ESTÀ SATISFEITO (A) CONSIGO MESMO (A) ___________

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FISÍCA E INTELECTUALMENTE_____________________________
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O QUE VOCÊ MAIS ADMIRA EM SI MESMO COMO

QUALIDADE?_______________________________________________
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E O QUE GOSTA MENOS?____________________________________

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GOSTARIA DE SER DIFERENTE DO QUE É?___________________

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COMO VOCÊ REAGE AS COISAS QUE O IRRITAM?___________

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EXTERIORIZA OU NÃO?_____________________________________
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COMO REAGE ÀS CONTRARIEDADES?_______________________

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COMO VOCÊ É?_____________________________________________

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O SEU NATURAL/ ALEGRE, PESSIMISTA, VARIÁVEL?_________

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VOCÊ SE SENTE CHATEADO (A) FREQUENTEMENTE?________

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COMO VOCÊ REAGE A ISSO?________________________________

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PROJETOS PARA O FUTURO

VOCÊ JÁ PENSOU NO QUE VAI FAZER?______________________

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SE JÀ PENSOU, DE ONDE VEM O INTERESSE?________________
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O ASSUNTO FOI DISCUTIDO COM ALGÉM?__________________

COM QUEM?________________________________________________

JÁ CONVERSOU COM OS PAIS A RESPEITO DESSES

PROJETOS?_________________________________________________
COMO REAGEM?___________________________________________
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QUAIS AS DIFICULDADES QUE VOCÊ VÊ EM RELAÇÃO À

REALIZAÇÃO DESSES PROJETOS?___________________________
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IMPRESSÕES DA PSICÒLOGA

→ Completar a entrevista com observação sobre Cor, Tipo Físico,

Maneira de falar, Gestos, etc.. . Achou que a pessoa falou com
facilidade? Se sentiu pouco a vontade? Em que trecho? Sentiu que em
determinado trechos teve que forçar a pessoa a falar? Além dessas
houve alguma dificuldade especial?
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DATA DA ENTREVISTA: _____________________________

ROTEIRO DE ENTREVISTA COM PAIS (ANAMNESE) VISANDO

O ATENDIMENTO DA CRIANÇA OU PRÉ-ADOLESCENTE

IDENTIFICAÇÃO PESSOAL
Nome:_______________________________________________________
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Nacionalidade: _______________________________________________

Sexo: __________________________________

Idade:__________________________________

Residência:__________________________________________________
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Telefone:____________________________ Celular:_________________

Escola:______________________________________________________
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Grau:_______________________________________

Nome da Mãe:________________________________________________
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Nacionalidade:_____________________________ Idade:________Anos

Nível de Instrução:____________________________________________

Profissão ( A oficial e a que exerce):______________________________

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Nome do Pai:________________________________________________
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Nacionalidade:_____________________________ Idade:________Anos

Nível de Instrução:____________________________________________

Profissão ( A oficial e a que exerce):______________________________

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Informante:__________________________________________________

Situação do(a) Paciente na Constelação Familiar (Idade e sexo dos

irmãos, se houver):
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Motivo da Consulta
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ANTECEDENTES PESSOAIS

CONCEPÇÃO

Quanto tempo após o casamento?________________________________

A criança foi desejada?_________________Sexo esperado:__________

Abortos anteriores ( espontâneos ou provocados e época):___________

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Observações:_________________________________________________
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Gestação

Enjoou?______________________Quanto tempo?_________________

Vomitou?_____________________Quanto tempo?__________________

Teve inchaços? Perda de água? Quanto?__________________________

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Hemorragias? Quando?________________________________________
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Operações? Quais e Quando? Tipos de Anestesia?__________________

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Nervosismo e outros?__________________________________________
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Medicamentos? (Tóxicos, Calmantes)?___________________________

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Ameaça ou Tentativa de Abortos?_______________________________

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Radiografia? Quais e Quando?__________________________________
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Transfusão de Sangue?________________________________________

Tratamento Pré – Natal?_______________________________________

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Parto sem Dor?_______________________________________________

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Grupo Sanguíneo da Mãe?________________ RH da Mãe e do Pai?___

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Observações:_________________________________________________
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Parto

A termo?______________________ Local?_______________________
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Atendido por:________________________________________________

Tempo entre início das contrações e expulsão?_____________________

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Tempo de expulsão?___________________________________________

Parto: natural, induzido, com anestesia, fórceps alto ou baixo, cesárea.

____________________________________________________________
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Posição da criança ao nascer? (cabeça, ombros, nádegas):

____________________________________________________________
____________________________________________________________
Chorou logo?___________________ Quanto demorou?______________

Nasceu cianótico(a)?____________ Manobras de ressuscitação?______

Icterícia? Quanto Tempo?______________________________________

____________________________________________________________

Peso e comprimento ao nascer?_________________________________

____________________________________________________________

Valor obtido no apgar:_________________________________________

Observações:_________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

DESENVOLVIMENTO

Alimentação

Leite materno?____________ _____Boa sucção e deglutição?_________

____________________________________________________________

Mamadeira? (início e desmame)________________________________

____________________________________________________________
____________________________________________________________

Desmame foi abrupto ou progressivo? (materno e mamadeira)_______

____________________________________________________________
____________________________________________________________

Aceitou bem os alimentos sólidos?_______________________________

Rejeitou alimentação (época):___________________________________

____________________________________________________________

Vômitos habituais? Em que situação?____________________________

____________________________________________________________

Quando comeu sem ajuda?_____________________________________

____________________________________________________________

Toma as refeições com os familiares ou separadamente?_____________

____________________________________________________________

Apresentou ou apresenta perturbações digestivas? (diarréia, prisão de

ventre, aerofagias, etc.)________________________________________
____________________________________________________________
____________________________________________________________

Atitude familiar em relação aos problemas de alimentação?__________

____________________________________________________________
____________________________________________________________
____________________________________________________________

Observações:_________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

SONO

Respeitava horários desde bebê?________________________________

____________________________________________________________

Dormia tranquilamente?_______________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Chorou demais?________________ Quieto demais?________________

Dorme bem?_______ Quantas horas?____________________________

____________________________________________________________

Sono atualmente: Agitado, Acorda a noite chorando, Assustado, Fala

ou Grita dormindo, é Sonâmbulo (a)_____________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Tem rituais para adormecer? E quais?___________________________

____________________________________________________________
____________________________________________________________

Dorme com alguém no quarto ou dorme só?_______________________

____________________________________________________________
Desde quando?_______________________________________________
____________________________________________________________

Quando acorda vai para a cama com os pais?______________________

____________________________________________________________
____________________________________________________________

Atitude familiar em relação aos problemas de sono:________________

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Observações:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
DESENVOLVIMENTO MOTOR

Quando manteve a cabeça?_____________________________________

Quando firmou as pernas com apoio?____________________________

Quando sentou? ( Com e sem apoio)_____________________________

____________________________________________________________

Engatinhou?_________________________________________________

Andou Sozinho(a)?____________________________________________
____________________________________________________________

Era bebê mole ou firme?_______________________________________

Caia com freqüência?__________________________________________

Controle do esfíncter anal diurno e noturno:______________________

____________________________________________________________
____________________________________________________________

Controle do esfíncter vesical diurno e noturno:____________________

____________________________________________________________
____________________________________________________________

Houve dificuldades na educação da limpeza?______________________

____________________________________________________________
____________________________________________________________

Atitude familiar em relação a este problema:______________________

____________________________________________________________
____________________________________________________________

Mão que começou a usar frequentemente?(idade)__________________

____________________________________________________________
____________________________________________________________

Foi ensinado o uso de uma das mãos?____________________________

____________________________________________________________

È canhoto?__________________ Habilidade para lidar com objetos

pequenos?___________________________________________________
____________________________________________________________
____________________________________________________________

Esbarra nas coisas, deixa cair coisas das mãos?____________________

____________________________________________________________
____________________________________________________________
____________________________________________________________
È ágil (Bicicleta, corridas, escaladas, muros, etc.)___________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Tem bom ritmo?______________________________________________

Observações:_________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

DESENVOLVIMENTO DA LINGUAGEM

Quando apareceu o gorjeio?____________________________________

Balbuciou?(Silabação, pá, tá)___________________________________

____________________________________________________________

Repetição de Sílabas? (Papa, Tata)_______________________________

____________________________________________________________
____________________________________________________________

Palavras com Significação? (Au-au, dá)___________________________

____________________________________________________________
____________________________________________________________

Justaposição de Palavras? (Mamãe, Água, Nenê, Danda)____________

____________________________________________________________
____________________________________________________________
____________________________________________________________

Sentenças Completas?_________________________________________
____________________________________________________________
____________________________________________________________

Compreendido pela Mãe? (Quando)_____________________________

____________________________________________________________
____________________________________________________________

Compreendido por Todos? (Quando)_____________________________

____________________________________________________________
____________________________________________________________
____________________________________________________________

Prolação Perfeita? (Quando)____________________________________

____________________________________________________________
____________________________________________________________

Habilidade para contar fatos?___________________________________

____________________________________________________________
____________________________________________________________
____________________________________________________________

Línguas faladas em casa? (Entre os pais e com a criança)____________

____________________________________________________________
____________________________________________________________
____________________________________________________________

Algum problema de Fala?______________________________________

____________________________________________________________
____________________________________________________________

Época do aparecimento e evolução do quadro:_____________________

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Atitude dos familiares em relação aos Problemas de Fala?___________

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Observações:_________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

ESCOLARIDADE

Frequentou escola maternal? Jardim da Infância? Pré? Onde? Com

que idade?__________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Dificuldades neste período?_____________________________________

___________________________________________________________

Atitudes tomadas?____________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Escolas freqüentadas? (idade)___________________________________

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Mudanças de escola? (motivo)___________________________________

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Repetições (motivo)___________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Quando e onde foi alfabetizado?_________________________________

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Método utilizado?_____________________________________________
____________________________________________________________
____________________________________________________________

Dificuldades na leitura e escrita?________________________________

____________________________________________________________
____________________________________________________________
____________________________________________________________

Dificuldades em aritmética?____________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Falhas pedagógicas? (mudanças de professor, métodos inadequados,

ausência, etc.)________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Problemas que prejudicam o rendimento ( indisciplina, faltas, doenças,

limitações sensoriais, etc.)______________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Faz as lições espontaneamente?_________________________________

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Ajuda recebida:______________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Mantém-se atenta nas tarefas escolares? Em outras atividades?______

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

É irrequieto?_______________Tem boa memória?_________________

É rápido, lento ou normal em suas atividades? ____________________

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Tem êxito, fracasso ou é normal na escola?________________________

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Observações:_________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Sociabilidade

Quando sorriu na presença dos familiares?________________________

____________________________________________________________
____________________________________________________________

Foi criança sociável?__________________________________________

____________________________________________________________
____________________________________________________________

Procura estabelecer contatos com outras crianças?_________________

____________________________________________________________
____________________________________________________________

Tem facilidade?________________ É bem aceito(a)?________________

Consegue manter esses contatos?________________________________

____________________________________________________________
____________________________________________________________

Tem preferências por sexo, idade ou determinada criança?__________

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Com quem brinca? (vizinhos, colegas de escola, filhos de amigos)_____

____________________________________________________________
____________________________________________________________
____________________________________________________________

Nas brigas como reage? (chora, é agressiva, se retrai, etc.)___________

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Como se comporta com adultos em geral? Com os professores?_______

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Local freqüente de brinquedos? (em casa de amigos, clubes, etc.)

____________________________________________________________
____________________________________________________________
____________________________________________________________
___________________________________________________________

Sai sem a família com outras crianças?

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Reações características habituais ao ambiente? (agressivo, medroso,

tímido, excitado, passivo, dependente, negativista, etc.)
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Atitude dos familiares:

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Como reage a frustrações?
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Houve regressão no comportamento? (motivo aparente)

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Observações:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Sexualidade

Manifestou curiosidade sexual? (próprio sexo, manipulações, sexo

diferente, sobre nascimento, concepção, etc.)
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Teve orientação, quem a deu e como?

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Faz brincadeiras sexuais com outras pessoas?

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Masturba-se e em que situações?

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Atitude dos familiares:

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Observações:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Manipulações e tiques

Usou chupeta até quando e como foi tirada?

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Chupou o dedo até quando e como foi tirado?

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Rói unhas? _________________Outras manipulações?______________

____________________________________________________________
____________________________________________________________

Apresentou ou apresenta tiques?________________________________

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Atitude dos familiares:

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Observações:

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

MEDOS, BIRRAS, MENTIRAS

Apresentou ou apresenta medos? (de pessoas, animais ou coisas

imaginárias)
____________________________________________________________
____________________________________________________________
_________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Atitude dos familiares:
____________________________________________________________
____________________________________________________________
_______________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Inventa fatos não ocorridos?

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Tem amigos imaginários?______________________________________

____________________________________________________________

Mente?____________Em que situações?__________________________

____________________________________________________________
____________________________________________________________
____________________________________________________________
Observações:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
DOENÇAS

Tem ou teve alguma má formação ou defeito físico?

____________________________________________________________
____________________________________________________________
___________________________________________________________
___________________________________________________________

Moléstias da infância que teve? Alguma complicação?

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Diagnósticos e evolução:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Febres altas? (tipo, duração, freqüência)

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Desmaios? (tipo, duração, circunstância)

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Convulsões? (tipo, duração, circunstância)

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Crises de perda de fôlego? Em que condições? Seguida de convulsões?

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Dores de cabeça freqüentes?
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Dores abdominais? (tipo e freqüência)

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Quedas, pancadas na cabeça, etc, seguidas de desmaios ou

hemorragias?
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Distúrbios psicossomáticos, asma, alergias e distúrbios glandulares?

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Distúrbios Sensoriais

Visão

Enxerga bem?_______________Já consultou oculista?______________

Usa óculos? (motivo)__________________________________________

Tem ou teve estrabismo?_______________________________________

Audição
Tem problemas de audição?
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Em qual dos ouvidos?

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Quando e em que circunstâncias apresentou pela 1ª. vez a deficiência

auditiva?
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

O começo foi brusco ou progressivo?

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Prefere que lhe falem alto?

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Incomodam-no (a) os ruídos?
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Fala muito alto? Muito baixo?

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Entende o que se lhe diz?
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Olha nos lábios de quem fala?

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Como se faz entender (gestos, mímica, gritos, etc.)

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Indagar se foi levado(a) a foniatra, fonoaudiólogo, neurologista,

psiquiatria, psicólogo (registrar o motivo e resultado da consulta ou
tratamento)
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Já fez eletroencéfalograma? Por que? Qual o resultado?____________

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Algum outro exame? Quais o resultados?_________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Observações:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

____________________________________________________________
____________________________________________________________
____________________________________________________________
ROTINA DE VIDA

Tem horários regulares para as refeições e sono? Quais?

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Respeita espontaneamente estes horários?

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
É independente na realização dos hábitos de rotina? (vestir, lavar,
escovar dentes, etc.)
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Qual o seu horário escolar?

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Tem atividades extra-escolares regulares e como se distribuem? (aulas

particulares, língua estrangeira, religião, ballet, ginástica, natação,
música, etc.)
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Outras atividades ocasionais? (esportivas, recreativas, sociais,

culturais)
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Qual o tempo que dispõe para os deveres escolares?

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Para as atividades de sua escolha?

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Observações:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

AMBIENTE

Inter-relacionamento familiar:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Relacionamento com a mãe?

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Com o Pai?
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Com os irmãos?
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Outros familiares?
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Relacionamento dos pais entre si?

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

NIVEL SÓCIO-ECONÔMICO

(Sublinhar sua apreciação subjetiva) inferior, médio inferior, médio,

médio superior, superior.

____________________________________________________________
____________________________________________________________
___________________________________________________________
____________________________________________________________
NIVEL CULTURAL

(Sublinhar sua apreciação subjetiva) inferior, médio inferior, médio,

médio superior, superior.
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

AMBIENTE MATERIAL

(Tipo de residência, local para recreações, para estudos, etc.)

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Observações:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

ANTECEDENTES
Houve ou há na família: pessoas nervosas, débeis mentais, com
convulsões, tiques, psicoses, internados, alcoólatras, toxicômanos,
presos, viciados em jogo (grau de parentesco)
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
__________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Pessoas com asma, sintomas alérgicos ou outros sintomas

psicossomáticos? (grau de parentesco)
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
OUTRAS OBSERVAÇÕES:___________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
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____________________________________________________________
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____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

SOCIEDADE ESPÍRITA MARIANO DO NASCIMENTO

PSICÓLOGA SANDRA FONE: 3629-1090

DATA:_______________ HORA:__________

NOME:_____________________________________________________
______________________________________________
* Caso não possa comparecer, favor avisar com antecedência

SOCIEDADE ESPÍRITA MARIANO DO NASCIMENTO

PSICÓLOGA SANDRA FONE: 3629-1090

DATA:_______________ HORA:__________
NOME:_____________________________________________________
______________________________________________
* Caso não possa comparecer, favor avisar com antecedência

SOCIEDADE ESPÍRITA MARIANO DO NASCIMENTO

PSICÓLOGA SANDRA FONE: 3629-1090

DATA:_______________ HORA:__________

NOME:_____________________________________________________
______________________________________________
* Caso não possa comparecer, favor avisar com antecedência

SOCIEDADE ESPÍRITA MARIANO DO NASCIMENTO

PSICÓLOGA SANDRA FONE: 3629-1090

DATA:_______________ HORA:__________

NOME:_____________________________________________________
______________________________________________
* Caso não possa comparecer, favor avisar com antecedência

ATENDIMENTO EM GRUPO
01/03/07- 8:30hs -Quinta-feira/ Primeiro
Idade de 55 a 80 anos
CONTATOS
N° NOME IDADE TEL CONTATO
1 Hilda Grellet 65 anos 3638-2323
2 Anésia Santos 66 anos 3628-1009
3 Nilda Sumida 55 anos 3627-2893
4 Ireni Sobrinho 3979-6823 9992-4564
5 Leila Santos 74 anos 3624-7561
6 Antonia Costa 57 anos 3624-7821
7 Cacilda Silva 55 anos 3965-6795
8 Sebastiana Lucas 74 anos 3623-8352
9 Maria Bento 71 anos 3902-3012
10 Ana Alves 78 anos 3617-2037
11 Paulina Anzanello 3967-0518
12 Maria Ap. A. Rocha (016) 55 anos 3491-1191
13 Iraci S. Mazarom (016) 55 anos 3726-3864
14 Vera Nandi 69 anos 3625-4788
15 Lourdes Cintra 66 anos 3615-0388
16 Benedita A. Oliveira (016) 67 anos 3945-2690
17 Olga Lana 70 anos 3636-2528
18 Dino Capri 76 anos 3623-1984
19 José Carlos Theodoro 70 anos 3629-1850
20 Maria Liça 75 anos 3620-2063
21 Olga Poletti Furiama 70 anos 3633-1036
22 José Ribeiro 62 anos 9175-0028
23 Maria José Dalossa anos 3617-2037
24 Marli A. Bononi 57 anos 3624-7706
25
26
27
28
29
30
31
32
33
34
35
36

ATENDIMENTO EM GRUPO
Quarta- Feira - 8:30hs
Idade de 25 a 54 anos
CONTATOS
N° NOME IDADE TEL CONTATO
1 Cirênia 41 anos 3639-7981
2 Andréia de Barros 39 anos 3975-6259 3602-2463
3 Márcia Nassaro 27 anos 3618-1877
4 Tânia Teixeira 44 anos 3966-5087
5 Marina Gomes 39 anos 3622-5674 (Tia)
6 Luciana Barbosa 33 anos 3941-1072
7 Vanessa Oliveira 33 anos 3638-1120
8 Márcia Basso * 32 anos 3969-1516
9 Alessandra Corazza 35 anos 3612-0846
10 Glauco Lima 41 anos 3625-7514
11 André Basso * 39 anos 9205-0949
12 Avani Martins 51 anos 3617-7311
13 Alessandra R. Corazza 35 anos 3612-0346
14 Leda Reginato 52 anos 3625-7246 9723-6940
15 Valdivia Vieira Silva (016) 38 anos 3953-4218 (sogra)
16 Luciana A. Oliveira 26 anos 3917-0179
17 Brenda Mazer (016) 46 anos 3942-1548
18 Rosangela Dias (016 anos 3946-9600 3942-4975
19 Alexandre Dias (016) 28 anos 3946-9600 3942-4975
20 Jane F. Oliveira anos 3976-5016
21 Sueli Watanabe 44 anos 3630-6287
22 Euterpe Simões da Silva 34 anos 3975-6375
23 Maria Ap. N. Monteiro 46 anos 3964-6407 9704-6535
24 Gisele E. G. Bruno 23 anos 3624-9951
25 Maristela Paula Giordano 21 anos 8156-8126
26 Márcia M. do Nascimento 33 anos 9224-0437
27 Maria Ap. Lopes Veloso 42 anos 3919-0248
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