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PSICOPEDAGOGIA INSTITUCIONAL E CLINICA

ACADMICA:_______________________________________________________
LOCAL DA ENTREVISTA:_____________________________________________
DATA:____/_____/________
ENTREVISTADO:___________________________________________________
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FICHA DE ANAMNESE
1. DADOS PESSOAIS:
Nome:___________________________________________________________
Data de Nascimento:_____/____/______ Idade____ anos _____ meses
Filiao: me:______________________________________________________
Pai:______________________________________________________________
Profisso da me:__________________________________________________
Profisso do pai:___________________________________________________
Endereo:_________________________________________________________
N de irmos (idades):_______________________________________________
2. QUEIXA:
Quando surgiu? Quem detectou? Quais as atitudes tomadas?
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3. ANTECEDENTES NATAIS
3.1 Quais foram as condies da gestao?
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3.2 Quais foram as expectativas que o casal tece em relao ao beb durante a
gravidez?____________________________________________________________
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3.3 Como a criana entrou na histria do casal?
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Condies Peri-Natais
3.4 Qual foi o tipo de parto?______________________________________________
3.5 Como ocorreu o parto?_______________________________________________
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3.6 Por que foi escolhido esse tipo de parto?_________________________________
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Neo-Netais
3.7 Como foi a adaptao de recm-nascido ao novo meio? (choro, sono e
alimentao)?________________________________________________________
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3.8 Como foi a adaptao da famlia em relao ao beb?_____________________
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4. DOENAS E TRAUMATISMOS
4.1 Terror noturno ( ) sim ( ) no
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4.2 Sonambolismo ( ) sim ( ) no
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4.3 Convulses ( ) sim ( ) no
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4.4 Toques nervosos ( ) sim ( )no
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4.5 Priso de Ventre ( ) sim ( ) no
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4.6 Problemas Ortopdicos ( ) sim ( ) no
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4.7 Alergia ( ) sim ( ) no
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4.8 Insuficincia Cardaca ( ) sim ( )no
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4.9 Insuficincia respiratria ( ) sim ( ) no
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4.10 Doenas Infantis ( ) sim ( ) no
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4.11 Outras doenas ( ) sim ( ) no
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5. DESENVOLVIMENTO

- Desenvolvimento Motor
5.1 Em que idade comeou a engatinhar?________________________________
Obs:________________________________________________________________
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5.2 Em que idade comeou a andar?____________________________________
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5.3 Problemas no desenvolvimento motor? ( desenvolvimento de linguagem)
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5.4 Em que idade comeou a balbuciar?____________________________________
Obs:________________________________________________________________
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5.5 Em que idade comeou a falar as primeiras palavras?____________________
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5.6 ouvi bem? ( ) sim ( ) no / Por qu?________________________________
Obs:________________________________________________________________
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5.7 Problemas do desenvolvimento da linguagem?_________________________
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Obs:________________________________________________________________
6. APRENDIZAGEM
6.1 - Quando a criana adquiri uma pauta nova de conduta ela passa a ser
autnoma ou precisa do adulto constantemente para ajud-la?
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PROCESSO ASSIMILATIVO
6.2 Quando e como se deu o desmame?
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6.3 Houve resistncia a mudana de
alimentao?_________________________________________________________
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6.4
Houve rejeio da
alimentao?________________________________________
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6.5
Como foi a reao aos
talheres?_____________________________________
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PROCESSO ACOMODATIVO
6.6
Quando e como a criana conseguiu controlar os
esfncteres?_____________
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6. 7 Foi castigado?_________________________________________________
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SITUAES DOLOROSAS
6.8
Houve perdas de pessoas por morte? ____________________________
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6.9
Como a criana reagiu?__________________________________________
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6.10 Como a famlia enfrentou a situao?
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6.11 A criana sente medo? De qu?
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6.12 Houve perdas por mudanas? (escola, bab, etc)
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6.13 Com a criana reagiu?
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6.14 Como a famlia enfrentou a situao?
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INFORMAES
6.15 Como so dadas as informaes do mundo externo criana?
Sexo:_______________________________________________________________
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Morte:______________________________________________________________
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ESCOLARIDADE
6.16 Em que idade a criana entrou na escola?
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6.17 Como a criana reagiu a esse primeiro contato?
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6.18 Como foi o relacionamento com os professores?_______________________
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6.19 Como foi a adaptao em cada ciclo?
*Pr-escolar?
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*Em qual srie/ano estuda:
1 seguimento do ensino fundamental
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Nome da escola:_____________________________________________________
6.20 O que a escola significa para a famlia?
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6.21 Que expectativa a famlia tem da escola?
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7 Como e quem faz a criana dormir?____________________________________
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8 Como o sono da criana?
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9 A quem a criana mais unida dentro da famlia?
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10 Os pais conversam com a criana? Sobre o qu?
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Quando a criana contrariada, qual a sua reao? ( a da criana e a dos pais)
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Pai e me adotam o mesmo regime quanto a educao da criana? Qual?
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Com est a relao afetiva do casal?
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Com quem a criana brinca?
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Qual a brincadeira predileta da criana?
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A criana v programas de televiso? Quais?
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O que os pais pensam sobre a criana? (temperamento/ caractersticas/
personalidade)
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ACOMPANHAMENTOS REALIZADOS
Psicolgico:__________________________________________________________
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Fonoaudiologico:______________________________________________________
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Outros:______________________________________________________________
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Exames apresentados
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Laudos apresentados
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Hiptese diagnstica
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Observaes complementares:
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Porto Velho, RO, ______/________/__________

PSICOPEDAGOGA:__________________________________________________