ANAMNESE

Nome: ___________________________________________________________________
Data de Nascimento:___/___/_______ Sexo:__________________________
Grupo Sanguíneo: ______ Fator Rh:_______
Endereço:__________________________________________________________________
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Série: _______________________________
Em Caso de emergência ligar para:
1-_________________________________________________________________________
2-_________________________________________________________________________
3-_________________________________________________________________________
Alérgico? ( )Sim ( )Não
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Faz uso de medicamento de forma contínua?
( )Sim ( )Não
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Em caso de dor ou febre o(a) aluno(a) pode usar algum tipo de medicamento? Qual?
Dosagem?
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É PcD?
( )Sim ( )Não
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Em caso de laudo ou investigação, favor comunicar à escola e trazer comprovação da CID.
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Deseja fazer alguma observação?
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Nome da mãe: ______________________________________________________________
Data de Nasc.: ____________________________________________
Telefone: _______________________________________________
Nome do Pai: _______________________________________________________________
Data de Nascimento: _______________________________________
Telefone: ________________________________________________

O(a) aluno(a) v ai para casa sozinho(a)? sim( ) nâo( )

Quem é o responsável por buscar o (a) aluno(a) na escola?
1- __________________________________ Tel:. _______________________________
2- __________________________________ Tel.:_______________________________

Data: ___________________________
Assinatura Responsável: ____________________________________________________