Escolar Documentos
Profissional Documentos
Cultura Documentos
1.DADOS DE IDENTIFICAÇÃO
Nome:_________________________________________________________________
Data de nascimento:__/__/__ Idade:_____
Religião:_______________________________________________________________
Curso:______________________________Centro:___________________Período:___
Matrícula:______________________________________________________________
Contrato:_______________________________________________________________
Encaminhado por:________________________________________________________
Encaminhamento:________________________________________________________
Profissional responsável:__________________________________________________
2.DADOS DE IDENTIFICAÇÃO DOS PAIS:
Nome do Pai:___________________________________________________Idade:___
Profissão:______________________________Empresa:_________________________
Grau de instrução:________________________________________________________
Endereço:______________________________________________________________
Telefone:_______________________________________________________________
Estado civil:_________________________E-mail:_____________________________
Nome da Mãe:__________________________________________________Idade:___
Profissão:______________________________Empresa:_________________________
Grau de instrução:________________________________________________________
Endereço:______________________________________________________________
Telefone:_______________________________________________________________
Estado civil:_________________________E-mail:_____________________________
3.QUEIXA PRINCIPAL:
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4.EVOLUÇÃO DA QUEIXA:
- Início da queixa:
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- Súbita ou progressiva:
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- Quais as mudanças que ocorreram? O que afetou?
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- Sintomas:
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5.QUEIXAS SECUNDARIAS:
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6.HISTÓRIA CLÍNICA:
- Casos de internação:
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- Enfrentamento:
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- Sintomas físicos e ou psicológicos:
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- Psicoterapia/fono/fisio/neuro/psiquiatria:
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- Hábitos alimentares:
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- Para crianças ou adolescentes:
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- Condições de nascimento:
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- Desenvolvimento neuropsicomotor:
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- Doenças infantis:
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- Caso de convulsão, epilepsia, desmaios etc:
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7.HISTÓRICO FAMILIAR:
- Composição familiar:
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- Dinâmica Familiar:
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- Eventos Significativo:
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- Rede de Apoio:
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8.HISTÓRIA SOCIAL:
- Vida Social:
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- Hábitos de lazer:
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- Inserção em grupo:
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- Rede de Apoio:
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9.DADOS ESCOLARES
- Caso de reprovação:
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- Área de dificuldade:
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- Hábitos de estudos:
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10.CONSIDERAÇÕES FINAIS:
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11.SUGESTÕES DE ENCAMINHAMENTO:
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