Professional Documents
Culture Documents
I- IDENTIFICAO
Nome: ________________________________________________________________
Idade: ________________________ Data de Nasc.: ____________________________
Sexo: ________________________ Cor: _______________ Ano: _________________
Escola:_________________________________ Ano: __________________________
Encaminhada: _____________________________________ Data: ________________
Sabe a razo de estar aqui? ( ) No ( ) Sim Qual : ____________________________
__________________
Concorda em estar aqui? ( ) No ( ) Sim
Por que: _____________________________________________
Telefones de contato:
_____________________________Tel.: _________-____________
_____________________________Tel.: _________-____________
_____________________________Tel.: _________-____________
PAI
Nome: ________________________________________________________________
Profisso: __________________________________________ Idade: ______________
ME
Nome: ________________________________________________________________
Profisso: __________________________________________ Idade: ______________
II- QUEIXA OU MOTIVO DA CONSULTA
Queixa principal: ________________________________________________________
H quanto tempo? _________
Outras queixas: ________________________________
H quanto tempo? __________
Atitude frente s queixas:
a) me: _______________________________________________________________
b) pai: ________________________________________________________________
c) parentes: ___________________________________________________________
III- ANTECEDENTES PESSOAIS
1- Desenvolvimento:
a) Sono:
Dorme bem? ___________________________________________________________
Tem horrio para dormir? ________________________________________________
Pula quando dorme? _____________________________________________________
Insnia? __________________________________________________________
Sudorese durante a noite? _________________________________________________
Acorda varias vezes durante a noite e torna a dormir facilmente? __________________
Quem as usa?___________________________________________________________
Quais as reaes da criana frente a essas medidas?_____________________________
Observaes:___________________________________________________________
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h) Doenas:
Teve quais? ____________________________________________________________
Idade: ________________________________ Como passou? ___________________
Atitude da famlia: ______________________________________________________
Febre nessa doena? _________________________Quantos graus? _______________
Convulses com febre? __________________________________________________
Convulses a verminoses? ________________________________________________
Desmaios? ______________________ Ficou roxo alguma vez? __________________
Ficou duro? ______________________ Ficou mole? ___________________________
Sofreu alguma operao? ___________________________ Idade: ________________
Com ou sem anestesia? _____________________________ Vacinas? _____________
Com febre? ___________________________________ Quantos graus? ___________
Usa algum tipo de medicamento?
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IV ANTECEDENTES FAMILIARES:
Algum nervoso na famlia? ______________________________________________
Como este nervoso? ____________________________________________________
Algum dbil mental na famlia? ___________________________________________
Algum internado? ______________________ Algum bebe? ___________________
Algum joga? _____________________ Algum fugiu de casa? _________________
Algum com asma? _______________________ Algum com alergia? ____________
Algum com ataques? ___________________________________________________
V - AMBIENTE FAMILIAR SOCIAL:
1- Ambiente material: __________________________________________________
Tipo de residncia: ___________________________________________________
Local para brincar: __________________________________________________
Local para estudo: ___________________________________________________
2- Inter-relaes:
Relao entre os pais: ________________________________________________
Relao entre a me e a criana: _________________________________________
3- Religio: ____________________________________________________________
4- Ambiente Social:
A famlia faz visitas? __________________________________________________
A famlia recebe visitas? _______________________________________________
Quem so os companheiros da criana? ___________________________________
Quem os escolhe?
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