Nome Completo:____________________________________________________________

Data de Nascimento:_________________ Idade: _________

Sexo:____________________________

Encaminhado por:

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Queixas (sintomas, duração, história pregressa de queixa)

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Intercorrências na Gestação
⃝ Sim ⃝ Não

Caso sim, qual?

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Tipo de Parto
⃝ Normal ⃝ Cesárea
Idade Gestacional
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Alta Hospitalar com a mãe

⃝ Sim ⃝ Não

Tempo de Amamentação
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Problemas de Sucção
⃝ Sim ⃝ Não

Quando começou a andar?

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Quando começou a falar?

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Frequência Escolar

⃝ Sim ⃝ Não

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Alteração Comportamental (Casa/Escola)

⃝ Sim ⃝ Não

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Avaliação de Linguagem (Aspectos linguísticos – sintaxe, semântica,

pragmática, fonética, fonologia)

Linguagem Oral

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Linguagem Escrita

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Internações, Medicamentos em uso

Exames Realizados

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Hipótese Diagnóstica

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Conduta

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