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ENTREVISTA DE TRIAGEM
Estagiário entrevistador:_____________________________________________________________
Professor supervisor:_______________________________________________________________
Data (s) da(s) entrevista(s): __________________________________________________________
Data em que procurou o SPA: ________________________________________________________
1 – IDENTIFICAÇÃO:
Nome:___________________________________________________________________________
Nome da mãe: ______________________________Nome do pai:___________________________
Idade:_______Data de nascimento: ___________Sexo:_____Estado civil: _____________________
Ocupação: ____________________________________Grau de instrução:____________________
Local de residência: ________________________________________________________________
Telefone: _____________________________ e.mail _____________________________________
Religião: _________________ Naturalidade: ______________ Nacionalidade: _______________
5 – HISTÓRIA FAMILIAR (estrutura familiar, problemas doenças e conflitos, história conjugal, etc.)
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10 – OBSERVAÇÕES COMPLEMENTARES:
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HIPÓTESE DIAGNÓSTICA:
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INDICAÇÃO DE TRATAMENTO:
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