ESCOLA DE CIÊNCIAS DA SAÚDE - ECS

CURSO DE FONOAUDIOLOGIA
CLÍNICA DE FONOAUDIOLOGIA

PROTOCOLO DE ENTREVISTA INICIAL/ANAMNESE1

Número do Prontuário Único: ____________________

Data da Entrevista: ___________________________________________________
Cidade de origem:_____________________________________________________
UBS que o paciente está alocado: ________________________________________
Nome do Estagiário (a): ________________________________________________
Nome do Orientador: ______________________________________________

A – DADOS DE ENTREVISTA:
I – DADOS DE IDENTIFICAÇÃO:
Nome do Paciente: __________________________________ Idade: ___________
Data de Nascimento: ____________________
Nome da Mãe: ______________________________________ Idade: ___________
Profissão:___________________________________________________________
Nome do Pai: _______________________________________ Idade: ___________
Profissão: ___________________________________________________________
Endereço: ___________________________________________________________
Telefones para Contato: ________________________________________________
Nome da Escola: _____________________________________________________
Série que Estuda:__________ Nome do Professor: __________________________
Endereço da Escola:___________________________________________________
Telefone da Escola: ___________________________________________________
Encaminhado por: ____________________________________________________
Genetograma:

1 Este protocolo foi elaborado por fonoaudiólogas professoras do Curso de Fonoaudiologia da

UNIVALI.
II – HISTÓRIA PESSOAL:
1 – Motivo da consulta (queixa): _________________________________________
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2 – História Pregressa do Distúrbio Atual (exploração da queixa – tipo de

sintoma, quando iniciou, como iniciou, o que chamou a atenção, hábitos do
paciente que possam estar relacionados a origem do problema, etc.; atitude da
família frente a queixa; parecer da família quanto a queixa; outros recursos
(atendimentos) utilizados para tratar do problema (Fono, Psico, Fisio, etc.)):
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3 – Antecedentes:
a) Concepção: _______________________________________________________
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b) Gestação: _________________________________________________________
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c) Parto: ___________________________________________________________
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d) Doenças: _________________________________________________________
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e) Informações complementares: ________________________________________

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4 – Rotina Diária:

a) Alimentação: ______________________________________________________
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b)Sono: _____________________________________________________________
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c)Brincadeiras/lazer: __________________________________________________
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d)Escolaridade: ______________________________________________________
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e)Atribuições no lar: __________________________________________________

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f) Descrição de um dia do paciente: ______________________________________

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g)Informações complementares _________________________________________

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5 – Linguagem (desenvolvimento e/ou situação atual):

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6 – Audição (desenvolvimento e/ou situação atual):
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7 – Motor/psicomotor (desenvolvimento e/ou situação atual):

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8 – Psicossocial (desenvolvimento e/ou situação atual) (tiques, medos, hábitos,
autonomia, independência, relacionamentos...):
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III – HISTÓRIA FAMILIAR:

1 – Antecedentes:
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2 – Ambiente familiar:
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3 – Condições sócio-culturais:
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IV – OUTROS DADOS:
1 – Impressões sobre o(s) entrevistado(s):
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2 – Participantes da entrevista:
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3 – Tratamentos atuais:
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4 – Resultados de exames médicos:

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5 – Diagnóstico de outros profissionais:
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6- Redes de Apoio:
A- Diversas (ESF, igrejas, grupos diversos, associações, etc)
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B- Técnicas (Referência/contato dos profissionais envolvidos)

Nome:______________________________Especialidade: ________________
Contato: ________________________________________________________
Nome:______________________________Especialidade:________________
Contato: ________________________________________________________
Acompanhamento ESF: ____________________________________________

V – OBSERVAÇÕES:
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Estagiário (a) Estagiário (a)

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Nome do Orientador por extenso e CRFa: 3__