Pronturio:___________ Data Admisso: __/___/___

01- DADOS DE IDENTIFICAO:

Nome:
Data de Nascimento: Idade:
Religio: Estado Civil:
Cidade Natal: Estado Natal:
Endereo:

Telefone Fixo: Celular: Recado:

Watts:
E-mail:

Quem sabe que esta em terapia:

Contato em emergncia:
Escolaridade:
Empresa em que trabalha:
Horrio:
Funo:
ENCAMINHAMENTO:
PROFISSIONAL RESPONSVEL:

02- DADOS DE INDENTIFICAO DOS PAIS:

Nome Pai: Idade:
Profisso: Empresa:
Grau de instruo:
Nome Me: Idade:
Profisso: Empresa:
Grau de instruo:
Endereo:

03- QUEIXA PRINCIPAL:

04- EVOLUO DA QUEIXA:

-Prioridade: __________________________________________________________________________
-Incio da queixa:______________________________________________________________________
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- Sbita ou progressiva:_________________________________________________________________
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- Quais as mudanas que ocorreram/ o que afetou:____________________________________________

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- Sintomas:___________________________________________________________________________
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05- QUEIXAS SECUNDRIAS:

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06- HISTRIA CLNICA:

-Doena crnica:
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-Uso de medicamentos. Quais:

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-Casos de internao:
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-Enfrentamento: _______________________________________________________________________
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-Sintomas fsicos e/ou psicolgicos:________________________________________________________
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- Psicoterapia/fono/fisio/neuro/psiquiatria:
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- Hbitos Alimentares:
Para crianas ou adolescentes:
- Condies de Nascimento:
- Desenvolvimento Neuropsicomotor:
- Doenas infantis:
- Casos de convulses,epilepsia,desmaios etc: -

07- HISTRIA FAMILIAR:

Composio Familiar: (genotograma)

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-Dinmica Familiar:____________________________________________________________________
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- Eventos Significativos:________________________________________________________________
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-Rede de Apoio:

08- HISTRIA SOCIAL:

- Vida Social:
- Hbitos de lazer:
- Insero em Grupos:
- Rede de Apoio:

09- DADOS ESCOLARES:

- Casos de reprovao:
- reas de dificuldade:
- Hbitos de Estudo:.

10- CONSIDERAES FINAIS::

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