ENTREVISTA DE ANAMNESE PSICOLÓGICA

NOME: _______________________________________________________________________
DATA/NASCIMENTO: ___/___/___ IDADE: __________________
ESCOLA: ___________________________________SÉRIE: ______TURNO:_____________
PAI: __________________________________________________________________________
MÃE: _________________________________________________________________________
RESPONSÁVEL ATUAL: _______________________________________________________

QUEIXA PRINCIPAL:
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GESTAÇÃO E PARTO:
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USOU DROGAS, ÁLCOOL OU FUMO NA GRAVIDEZ?

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ANTECEDENTES PATOLÓGICOS FAMILIARES:

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ALIMENTAÇÃO:
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QUANTO AO SONO: BRUXISMO, SONAMBULISMO, TERROR NOTURNO, ALGUM

OUTRO DISTÚRBIO? DORME COM QUEM?
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DESENVOLVIMENTO PSICOMOTOR:

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DESENVOLVIMENTO DA LINGUAGEM:
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ASPECTOS SÓCIO-EMOCIONAIS, COMPORTAMENTAIS E COGNITIVOS:

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COMO FOI O CONTROLE DOS ESFÍNCTERES? ENURESE NOTURNA OU DIURNA?

ECOPRESE NOTURNA?
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SOCIALIZAÇÃO NA ESCOLA, EM CASA E NOS DEMAIS ÂMBITOS?

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EVOLUÇÃO DA SEXUALIDADE, ORALIDADE, MASTURBAÇÃO. OS PAIS

ORIENTAM?
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COMO É O RELACIONAMENTO FAMILIAR? EXISTEM MOMENTOS DE LAZER

E/OU ATIVIDADES LÚDICAS COM A CRIANÇA? CONFLITOS FREQUENTES?
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NÍVEL SÓCIO-ECONÔMICO, COM QUEM MORA, QUANTAS PESSOAS TÊM NA
FAMÍLIA? TÊM AGREGADOS?
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HOUVE INTERFERÊNCIA NA EDUCAÇÃO DA CRIANÇA?

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ATENDIMENTOS MÉDICOS OU TERAPÊUTICOS ANTERIORES E ATUAIS? JÁ

REALIZOU ALGUM TRATAMENTO PROLONGADO E OU CIRURGIAS?
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PORTADOR DE ENFERMIDADE, NASCENÇA OU ADQUIRIDA?

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FAZ USO DE ALGUM MEDICAMENTO? QUAIS?

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ACIDENTES, ASSISTIDOS OU SOFRIDOS?

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COMO É O COMPORTAMENTO AFETIVO/EMOCIONAL DA CRIANÇA OU

ADOLESCENTE?
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QUAIS MÉTODOS DISCIPLINARES OS PAIS OU RESPONSÁVEIS UTILIZAM? E
COMO A CRIANÇA REAGE A REGRAS?
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EXAMES COMPLEMENTARES:
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ENCAMINHAMENTOS INTERNO:
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HIPÓTESE DIAGNÓSTICA:
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OBSERVAÇÕES:
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TEIXEIRA DE FREITAS, ______ DE _______________ DE 2017.

Cintia Stauffer de Freitas Barreto CRP – 03/2360

PSICÓLOGA / SUPERVISORA

ESTAGIÁRIO (A) / ALUNO PITÁGORAS