Secretaria de Educação

Coordenação da Educação Especial

Entrevista Inicial

Data: ____________

Nome:
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Nome da Mãe ou
Responsável:________________________________________________________________

Alérgico: ( ) S ( ) N
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Toma medicação: ( ) S ( ) N
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Profissionais que o acompanham:

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Reforçadores em potencial (objetos, pessoas, comida):

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Verbal: ( ) S ( ) N
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Interage bem: ( ) S ( ) N
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Olha no olho ao ser chamado: ( ) S ( ) N
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Seletividade alimentar: ( ) S ( ) N
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Brinca com função: ( ) S ( ) N

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Sabe o seu nome: ( ) S ( ) N

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Sabe as vogais: ( ) S ( ) N
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Sabe as cores: ( ) S ( ) N
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Sabe o alfabeto: ( ) S ( ) N
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Sabe os numerais: ( ) S ( ) N
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Sabe o nome dos responsáveis: ( ) S ( ) N
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Atende a comandos: ( ) S ( ) N
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Estereotipia: ( ) S ( ) N
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Ecolalia: ( ) S ( ) N
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Fixação: ( ) S ( ) N
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Dificuldade motora: ( ) S ( ) N
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Identifica as partes do corpo: ( ) S ( ) N
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Sensibilidade (Som, textura, toque): ( ) S ( ) N
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Resistência a algo: ( ) S ( ) N
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Gosta de música: ( ) S ( ) N
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Nomeia as cores? ( ) S ( ) N
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Nomeia objetos? ( ) S ( ) N
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Identifica Figuras? ( ) S ( ) N
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Usa telas? ( ) S ( ) N
O que assiste?
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Nomeia animais? ( ) S ( )
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Sabe as emoções? ( ) S ( ) N
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Sabe se expressar? ( ) S ( ) N
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Auto-agressão: ( ) S ( ) N
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Agressivo com os outros: ( ) S ( ) N
Em quais momentos?
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Gosta de animais? ( ) S ( ) N
_____________________________________________________________________________Sabe
se vestir sozinho? ( ) S ( ) N
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Sabe comer só? ( ) S ( ) N
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Tem autonomia para fazer o que?
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Tem noção de perigo? ( ) S ( ) N
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Outras observações:
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Gravidez: Tranquila ( ) Planejada ( ) Não Planejada ( ) Desejada ( ) Indesejada ( )

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Alguma medicação na Gravidez? S ( ) N ( )
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Os pais são parentes em algum grau? S ( ) N ( )
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Parto: Cesária ( ) Normal ( ) Alguma intercorrência?
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Perfil da Criança: Agitado ( ) Tranquilo ( ) Inseguro ( ) Impaciente ( )

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Desde quando perceberam algum desvio no desenvolvimento? Quem observou primeiro?
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A criança mamou? S ( ) N ( )
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Usou e ainda usa chupeta, dedo ou mamadeira? S () N ( )
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Engatinhou? S ( ) N ( ) Andou com quantos meses?
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Dorme sozinha? S ( ) N ( )
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A criança começou a balbuciar com que idade?
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O que mais gosta de fazer?

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Dificuldade na parte pedagógica?
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Dificuldade na interação social?
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Professor AEE: ______________________________________________________________