ENTREVISTA NEUROPSICOLÓGICA INFANTO-JUVENIL

Nome: ________________________________________________________________
Nome dos pais (ou responsáveis):
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Idade: _________ data nasc.: _____________

Escolaridade: ___________________ Instituição de ensino: _____________________
Solicitante: ____________________________________ Data: _________________

Motivo da Consulta:
Qual motivo do encaminhamento?
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Quais são os sintomas? Os sintomas são restritos a apenas um contexto? ____________

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Antecedente familiar:_____________________________________________________
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Histórico familiar: _______________________________________________________

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Os pais repetiram de ano na escola? (em casos de queixa de aprendizagem)

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Medicação e doenças pregressas:

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Já fez alguma avaliação neuropsicológica anteriormente?
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Faz algum acompanhamento médico?________________________________________

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Possui exames recentes?___________________________________________________

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Contexto Familiar:

Mora com quem?

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Quem cuida no dia a dia?_________________________________________________

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Tem irmãos? Mais velho ou mais novo?______________________________________

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Como é a dinâmica familiar?_______________________________________________

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Desenvolvimento (Gestação e os primeiros meses)

Gestação:
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Desenvolvimento motor:
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Desenvolvimento da Fala:
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Início do processo de escolarização (adaptação escolar):
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Contexto acadêmico (passado e atual):

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Como organiza seus objetos pessoais e material escolar:

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Como realiza as tarefas escolares (fatores ambientais) e como vivencia o processo de

aprendizagem:
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Como se relaciona com colegas e professores

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Concentração em atividades que demandam maior esforço cognitivo (lazer e escolares):

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Rotina e regras familiares:

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Como se relaciona com familiares

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Como lida com as frustrações:

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Observações:
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