quarta-feira, 26 de agosto de 2015

Avaliação Psicopedagógica - parte 1

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: _____________
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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Observações:
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