Entrevista Psicológica

1. IDENTIFICAÇÃO

1.1 CRIANÇA / ADOLESCENTE (Preencher quando paciente/cliente for criança ou adolescente)

NOME: ____________________________________________________________ IDADE: _______________

SEXO: F ( ) M ( ) DATA DE NASCIMENTO: ______/_______/________
ESCOLARIDADE: ______________________ RELIGIÃO DOS PAIS: ______________________________
NOME DO PAI: ___________________________________________________________________________
IDADE: __________________ ESCOLARIDADE/PROFISSÃO: ___________________________________
NOME DA MÃE: __________________________________________________________________________
IDADE: ___________________ ESCOLARIDADE/PROFISSÃO: ___________________________________
OUTRO RESPONSÁVEL: ___________________________________________________________________
IDADE: ___________________ ESCOLARIDADE/PROFISSÃO: __________________________________
GRAU DE PARENTESCO: __________________________________________________________________

ENDEREÇO: ______________________________________________________________________________
BAIRRO:___________________________________ CEP:____________________________________
TELEFONE RESIDENCIAL: _____________________ CELULAR: _____________________________

2. INFORMAÇÕES

2.1 QUEIXA PRINCIPAL:

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2.2 EVOLUÇÃO DA QUEIXA

INÍCIO DA QUEIXA:
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SÚBITA OU PROGRESSIVA:
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MUDANÇAS QUE OCORRERAM:

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2.3 QUEIXA SECUNDÁRIA

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2.4 HISTÓRIA BIOMÉDICA

DOENÇA CRÔNICA:
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USO DE MEDICAMENTO. QUAIS?

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CASOS DE INTERNAÇÃO:
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ENFRENTAMENTO:
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PSICOTERAPIA/FONO/NEURO/PSIQUIATRIA/OUTROS:
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HÁBITOS ALIMENTARES:
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SONO:
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2.5 HISTÓRIA FAMILIAR

COMPOSIÇÃO FAMILIAR:
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DINÂMICA FAMILIAR:
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EVENTOS SIGNIFICATIVOS:
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REDE DE APOIO:
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2.6 HISTÓRIA SOCIAL

VIDA SOCIAL/ HÁBITOS DE LAZER/ INSERÇÃO EM GRUPO:
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2.7 DADOS ESCOLARES

CASO DE REPROVAÇÃO E/OU ÁREAS DE DIFICULDADES:
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HÁBITOS DE ESTUDO:

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2.8 DESENVOLVIMENTO
CONDIÇÕES DE NASCIMENTO:
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DESENVOLVIMENTO PSICOMOTOR:
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DOENÇAS INFANTIS:
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CASOS DE CONVULSÕES, EPILEPSIA, DESMAIOS, ETC.:

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2.9 LINGUAGEM:
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2.10 ATIVIDADE DE VIDA DIÁRIA (AVD) E ROTINA AO LONGO DA SEMANA
AVDs ___________________________________________________________________________________
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DURANTE A SEMANA_____________________________________________________________________
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SÁBADO/DOMINGO_______________________________________________________________________
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2.11. IMPRESSÕES SOBRE O CLIENTE OU INFORMANTE:

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2.12. OBSERVAÇÕES COMPLEMENTARES:

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DATA DO ACOLHIMENTO: ________/________/________