FICHA DE ANAMNESE

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I. DADOS DE IDENTIFICAÇÃO:

Nome:
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Data de nascimento: ______/______/________ Idade: ____________ Sexo: F ( ) M ( )
Endereço:
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Reside com:
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Acompanhante:
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Parentesco:
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II. ENCAMINHADO:
Encaminhado por:
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Motivo do encaminhamento:
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Hipótese Diagnóstia:
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III. QUEIXA
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IV. DADOS DA HISTÓRIA

1. Como foi a gestação, parto e o desenvolvimento neuropsicomotor?
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2. Com que idade foi à escola?

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3. Como foi o processo de alfabetização?

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4. Quantas escolas já frequentou? Quais?
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5. Teve problema de adptação escolar?

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6. Precisou de reforço escolar?

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7. O que os professores relatavam?

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8. É agitado na escola? E em casa? Desde quando?

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9. Como é a sua atenção em casa e na escola?

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10. Atividades extracurriculares?

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11. Perde objetos?

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12. Possui dificuldade para se concentrar? Em que situação?

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13. Esquece onde coloca objetos?

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14. Tem dificuldade para concluir tarefas?

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15. Esquece algo que lhe foi falado?

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16. Esquece o que estava indo fazer ou falar?

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17. Esquece compromissos?

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18. Quando iniciaram as dificuldades? Foi de modo abrupto ou gradual? Veio piorando com o decorrer do tempo?
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19. Tem irmãos? Quantos? Idade:

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20. Como é a relação com eles?

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21. Tem algum medo?

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22. Tem alguma mania?

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23. É tímido? Em que situações:

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24. É dependente?
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25. Se coloca ou já se colocou em situação de risco? Quando?

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26. É lider ou submisso com colegas?

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27. Encontra os colegas fora da escola?

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28. É agitado, inquieto?

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29. Como lida com frustação?

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30. Como lida com limites e regras?

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31. Sente vontade de chorar? Quando?

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32. Faz amizade com facilidade ou não?
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33. Decreeve um dia desde ao levantar ao deitar?

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34. Dorme bem? Quantas horas por noite?

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35. Apresenta alguma problema de sono?

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36. É sonambulo?
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37. Dorme durante o dia?

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38. Apresenta alguma problema específio de saúde? Alguma doença na infância?

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39. Já foi hospitalizado? Por que?

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40. Tem algum problema de visão? Qual?
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41. Tem algum problema de audição? Qual?

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42. Já teve convulsões? Desmaios? Ausência?

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43. Toma remédio todo mês?

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44. Doenças na família?

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