Diagnstico Psicopedaggico

ANAMNESE II
1- DADOS DE IDENTIFICAO
Nome: ______________________________________ Naturalidade: ___________________________________
Data de Nascimento: ______/_______/_________ Idade: _________________________
Filiao: Pai __________________________ Idade_______ Profisso___________________________________
Me___________________________ Idade________ Profisso _______________________________________
Escolaridade _________________________ Srie ________ Repetncias _______________________________
Estabelecimento de Ensino ____________________________________________________________________
Endereo: residencial _________________________________________________________________________
Comercial __________________________________________________________________________________
Fones: residencial ______________ comercial _____________ contato______________
Lnguas faladas em casa _______________________________________________________________________
Informante _________________________________________________________________________________
2- MOTIVO DA AVALIAO DIAGNSTICA
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Encaminhado por ____________________________________________________________________________
Idade em que foi constatado o problema _________________________________________________________
Providncias tomadas na ocasio _______________________________________________________________
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3- ANTECEDENTES
Concepo (se a criana foi desejada, e o sexo, se foi concebida para salvar ou consolidar um relacionamento,
posio da criana frente aos irmos, idade dos pais na poca da concepo, abortos, etc.).
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Gestao (acidentes, hemorragias, ameaas de aborto, vmitos, enfermidades da gestante, raio X, RH, drogas
ou lcool, acompanhamento pr-natal, etc.).
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Parto (condies, tipo, complicaes, m formao, necessitou de oxignio, peso, comprimento, reflexos de
suco)
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4- DESENVOLVIMENTO
Sono (dorme bem, quanto tempo, acorda a noite, mexe-se demais na cama, fala dormindo, sonmbulo, vai
para a cama dos pais, range os dentes)
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Alimentao (dificuldades para mamar, boa suco, engolia bem, tempo de amamentao, mamadeira,
alimentao de slidos, alimentao atual, come sozinho)
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Linguagem (quando aconteceu, sorriso social, fala, balbucio, vocalizao, sons diferentes, frases, falou
corretamente, desenvolvimento atual, receptiva, expressiva e vocabulrio).
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Psicomotor (segue pessoas ou objetos que esto ao seu redor, quando: sustentou a cabea, sentou sozinho,
com e sem apoio, rastejou, engatinhou, andou, com auxlio, sem auxlio, dificuldades, equilbrio, agilidade)
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Scio-emocional (relacionamento com o ambiente, agressividade, dependncia, timidez, com os colegas, na
comunidade, idade mdia dos principais amigos, atividades grupais, isoladas, gosta de estar com outras
pessoas)
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5- DOENAS E ATENDIMENTOS MDICOS
Da criana (que doenas foram contradas pela criana, em que idade ocorreram, intensividade, acidentes,
cirurgias, fraturas, hospitalizaes, por quanto tempo, uso de medicamentos, exames e laudos mdicos,
convulses, febre, aspectos auditivos, visuais, EGG)
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Antecedentes de sade da famlia (houve algum da famlia com DM, DV, DF ou DA, alcolatras, internados,
epilticos, asma, alergias, tratamento psicoterpico)
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6- ATIVIDADES DE VIDA DIRIA
Hbitos de higiene (toma banho sozinho, se veste, cala meias, sapatos, se penteia)
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Responsabilidades por tarefas do lar (especificar)
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7- DINMICA FAMILIAR
Constelao Familiar
Nome _____________________________________________________________________________________
Idade _____________________________
Sexo ______________________________
Est. Civil___________________________
Parentesco ____________________________
Instruo__________________________________
Trabalho ___________________________________________________________________________________
Relacionamento dos pais entre si: _______________________________________________________________
Relacionamento dos pais com os filhos: __________________________________________________________

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8- TIQUES E MANIPULAES (chupa dedos ou objetos, ri unhas, enrola o cabelo)

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9- HISTRICO ESCOLAR (pr-escola, gostou de ir para escola, gosta de aprender coisas novas, recebe ajuda nos
estudos em casa, qual, reao da famlia frente a suas dificuldades, dificuldades na leitura ou escrita, algum
defeito de fala)
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Escolas que Freqentou _______________________________________________________________________
Srie ______________________________________________________________________________________
Ano _________________________________
10- OBSERVAES
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Data ______/_______/________
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Nome completo do profissional que procedeu a entrevista
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Assinatura e funo que exerce

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