Avaliao Psicolgica

Entrevista de Anamnese
1) Identificao:
Nome

do

Cliente:

_______________________________________

Data

de

Nascimento:

____/____/____
Nome dos Pais: _______________________________________________________________________
____________________________________________________________________________________
Pai: Nasc.: ____/____/____

Me: Nasc.:

____/____/____
Endereo: ____________________________________________________________________________
Telefone

Res:

______________

Telefone

Com:

_______________

Telefone

Celular:

_______________
Escolaridade:

_________________

Escola:

_________________________________________________
Responsvel: _________________________________________________________________________
2)

Atitudes

do

Entrevistado:

____________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________
3) Sntese dos dados da demanda atual:
Sade Fsica: _________________________________________________________________________
Uso

de

medicamentos?_____________

Quais?

______________________________________________
Atendimentos

anteriores:

________________________________________________________________
Sade

da

Famlia

em

geral:

______________________________________________________________
____________________________________________________________________________________
4) Constelao da Dinmica Familiar:
Nvel socioeconmico: _________________________________________________________________
Tipo

tamanho

da

habitao:

____________________________________________________________
__________________________________

de

cmodos:

_________

de

Moradores:

____________
Membros da Famlia:
Idade
Pai

Profisso

Nacionalid
ade

Sade

Temperame
nto

Escolarida
de

Idade

Sexo

Posio

Sade

Avaliao Psicolgica
Entrevista de Anamnese
Escolaridad
e

Irmos:
01
02
03
04
Outros

parentes.

Especifique:

____________________________________________________________
____________________________________________________________________________________
Interferncia

na

educao

da

criana:

______________________________________________________
Atmosfera do lar: ______________________________________________________________________
Relacionamento pai-me: ______________________________________________________________
Opinies

do

ponto

de

vista

educacional

discordncias:

_______________________________________
Relaes

pai-

filhos:_____________________________________________________________________
5) Antecedentes patolgicos e psicopatolgicos de familiares:
________________________________________________________________________________________
________________________________________________________________________________
6) Evoluo e desenvolvimento
a)

Condies

da

gestao:

______________________________________________________________
Gravidez?_____________________

Pr-natal? __________________________________

Sade Materna? _______________________________________________________________________

Idade

da

me:

_________________

Uso

de

medicamentos?

__________________________________
Ambiente Familiar: ___________________________________________________________________
b)

Condies

do

parto:

_______________________________________________________________
Local: __________________ Tipo: ___________ a termo: ___________ Peso:______ Altura:
________
Choro:

__________________

Ictercia:

___________

Anxia:

___________

Outros:

________________
c) Alimentao: ______________________________________________________________________
Tipo de Alimentao: __________________________________________________________________

Avaliao Psicolgica
Entrevista de Anamnese
Desmame: ___________________________________________________________________________
Distrbios

de

alimentao:

______________________________________________________________
Ansiedade Oral:

Alotriofagia (comer pano, papel):

____________________________________

Coprofagia (comer fezes):___________________________________________

Geogafia (comer terra): ____________________________________________
Outros especifique: ______________________________________________
d)

Evoluo

da

Psicomotricidade:

_______________________________________________________
Reflexos,

sustentao

da

cabea:

_________________________________________________________
Sentar,

arrastar,

engatinhar,

ficar

em

com

apoio:

__________________________________________
Marcha

ereta:

evoluo

_________________________________________________________________
Tombos: _____________________________________________________________________________
Coordenao motora: __________________________________________________________________
Atual: _______________________________________________________________________________
Grafismo: ____________________________________________________________________________
Lateralidade: _________________________________________________________________________
Brinquedos

motores:

___________________________________________________________________
Tiques

motores:

__________________________________________________________________________
Acidentes:
_______________________________________________________________________________
Observaes:
_____________________________________________________________________________
e)

Controle

de

esfncter:

____________________________________________________________________
Adaptao

inicial:

_________________________________________________________________________
Enurese

noturna:

________________________

Enurese

diurna:

____________________________________
Encoprese:

____________________________

constipao______________

Reteno:

urinria

___________

Avaliao Psicolgica
Entrevista de Anamnese
Observaes:
_____________________________________________________________________________
f)

Evoluo

da

Linguagem:

__________________________________________________________________
Balbucio:
________________________________________________________________________________
Linguagem

de

compreenso:

________________________________________________________________
Linguagem

de

uso:

_________________________________________________________________________
Linguagem

egocntrica:

____________________________________________________________________
Linguagem

socializada:

_____________________________________________________________________
Distrbios:
_______________________________________________________________________________
Observaes:
_____________________________________________________________________________
g)

Sono:

_________________________________________________________________________________
Adaptao

(ps-natal):

_____________________________________________________________________
Regularidade:
_____________________________________________________________________________
Distrbios:
_______________________________________________________________________________
Com

quem

dorme?

____________________________

Como

dorme?

________________________________
Sonhos?
_________________________________________________________________________________
h)

Socializao:

___________________________________________________________________________
Adaptao

inicial:

_________________________________________________________________________
Hbitos
________________________________________________________________________

higinicos:

Avaliao Psicolgica
Entrevista de Anamnese
Sociais:

Hbitos

___________________________________________________________________________
Relacionamento na famlia:
Me:

____________________________________

Pai:

____________________________________________
Irmos:

__________________________________

Parentes:_______________________________________
Amigos:

__________________________________

Grupos:

________________________________________
Participao

na

vida

domstica:

______________________________________________________________
Cooperao:
______________________________________________________________________________
Auxlio

mtuo?

___________________________________________________________________________
Facilidade

de

contatos:

_____________________________________________________________________
Cimes:
_________________________________________________________________________________
i)

Evoluo

da

sexualidade:

____________________________________________________________
Manipulaes: ________________________________________________________________________
Oralidade:

Suco:__________________

Chupeta:

_________________

Dedo

na

boca:______________
Masturbao: _________________________________________________________________________
Curiosidade sexual: ____________________________________________________________________
Orientao

dos

pais

com

relao

sexualidade:

______________________________________________
Observaes: _________________________________________________________________________
j) Escolaridade: ______________________________________________________________________
Incio

adaptao:

_____________________________________________________________________
Alfabetizao: ________________________________________________________________________
Dificuldades
______________________________________________________________

apresentadas:

Avaliao Psicolgica
Entrevista de Anamnese
Hbitos de estudo: _____________________________________________________________________
Ajustamento

no

ambiente

escolar

(socializao):

_____________________________________________
Opinio

sobre

escola:

_________________________________________________________________
Aspiraes

interesses:

_________________________________________________________________
l)

Tolerncia

frustrao:

_____________________________________________________________
Reao de PR: ________________________________________________________________________
Interesses

preferncias:

________________________________________________________________
m) Recreao:
Em casa: ____________________________________________________________________________
Esportes: ____________________________________________________________________________
Bairro: ______________________________________________________________________________
Domingos,

feriados,

frias:

______________________________________________________________
n)

Mtodos

disciplinares:

______________________________________________________________
Dilogo:

___________________

Punies:

_________________

Castigos

Fsicos:

_________________
Gritos:

____________________

Ameaas:

__________________

Prmios:

_______________________
Humilhaes:

_______________

Privaes:

_________________

Outros:

________________________
o)

Observaes

Complementares:

_______________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________
Aluno Responsvel: ____________________________________________________________________
Supervisor
________________________________________________________________

Responsvel: