ENTREVISTA PSICOPEDAGÓGICA
1 – IDENTIFICAÇÃO
PESSOAL:
Nome: ______________________________________________________
Sexo:( )M ( )F idade:______________
Nome da mãe: ______________________________________idade:_____
Nome do pai:_______________________________________
idade:_____
Endereço: __________________________________________Nº:
______
Bairro: _________________Cidade: ________________
CEP: ______-___
Fones: Fixo:____________Cel:_____________ Nascimento
: ___/____/___
Nacionalidade: (
)Bras. ( )outros_________
Cidade/Estado em que nasceu____________________ CPF: _____________
Cidade/Estado em que nasceu____________________
RG: ______________Órgão Expedidor: ________ UF: _____
2 – QUEIXA INICIAL:
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3 – HISTÓRIA
PREGRESSA DA QUEIXA:
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4 - HISTÓRICO ESCOLAR:
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5 – HISTÓRICO
FAMILIAR:
a) Como é o relacionamento com a
mãe?
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b) Como é o relacionamento com o
pai?
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c) Quem mais mora na casa?
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d) Gestação e Nascimento: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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e) Crescimento:
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f) Tem irmãos? Como é o relacionamento?
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6 – DADOS DA SAÚDE:
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7 – ASPECTOS DA
CONDUTA SOCIAL:
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