Diagnstico Psicopedaggico

HISTRIA DE VIDA
Data: __________________________
Dados obtido em entrevista com:____________________________________________________________
1. Identificao
Nome:
_______________________________________________________________________________________
Data de nascimento: ________________
Filiao:
Pai:___________________________________________________________________________________
Idade: ________ Profisso: _________________________________________________________________
Escolaridade:______________________________________________________________________________
Me:____________________________________________________________________________________
Idade: ________ Profisso: __________________________________________________________________
Escolaridade:______________________________________________________________________________
Escola: ______________________________________________ Fone: _____________
Srie: _________ Professor (a):_______________________________________________________________
Repetncias: _______________ Encaminhado por:_______________________________________________
Posio que ocupa em relao aos irmos:______________________________________________________
2. Antecedentes Natais
Gestao
Gravidez planejada? ( )sim
( )no
Com sentia-se a me durante a gravidez?_______________________________________________________
Doenas e/ou acidentes?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Acompanhamento mdico ( )sim ( )no desde___________________
Como foi a participao do pai durante a gravidez?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

Nascimento
Parto ( ) Cesria ( ) Normal
Durao: _________________________________________________________________________________
Choro: ___________________________________________________________________________________
Outros dados (RH, frceps, placenta prvia)
________________________________________________________________________________________
________________________________________________________________________________________
Neonatal
Sono____________________________________________________________________________________
Alimentao______________________________________________________________________________
Doenas__________________________________________________________________________________
Rotina (banho, horrios)
________________________________________________________________________________________
________________________________________________________________________________________
Relacionamento afetivo
________________________________________________________________________________________
________________________________________________________________________________________
Observaes
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
3. Desenvolvimento motor
Sentou ______________________ Engatinhou _________________________________
Andou_______________________ Equilbrio ___________________________________
Estmulos recebidos
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Da linguagem
Quando comeou a falar____________________________________________________________________
Dificuldades______________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
De hbitos
Controle dos esfncteres_____________________________________________________________________
Independncia do banho____________________________________________________________________
Vestir____________________________________________________________________________________
Sono ____________________________________________________________________________________
Outros dados_____________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
4. Aprendizagem
Estimulao cultural________________________________________________________________________
Interesses ________________________________________________________________________________
Relacionamento afetivo (famlia, amigos)
________________________________________________________________________________________
________________________________________________________________________________________

Escolaridade
Quando comeou: idade________ srie _________ Escola _________________________________________
Rendimento escolar ________________________________________________________________________
Dificuldades ______________________________________________________________________________
Relacionamento sujeito-escola, sujeito-colegas
________________________________________________________________________________________
________________________________________________________________________________________
Relacionamento famlia-escola
________________________________________________________________________________________
________________________________________________________________________________________
Outros dados
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
5. Atendimentos (fisioterapia, neurologia, psicologia, psicomotricidade)
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
6. Observaes
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

Organizado por Janaina Luna Psicopedagoga, Professora de Ingls e Portugus, Tradutora e Revisora de textos.