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diagnostico psicopedagogico
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ANAMNESE
Atendimento Educacional EspecializadoANAMNESE
DATA: ____/____/_______
I - IDENTIFICAO Nome da criana: ________________________________________________________________________
Data de Nasc: _____/_____/_________ Idade: ______________________
Nome da Me:___________________________________________________________________________
Nome do Pai: ___________________________________________________________________________
Responsvel pela criana:__________________________________________________________________
Telefones: ______________________________________________________________________________Quem reside na casa? ( composio familiar)NomeParentescoIdade
II HISTRICO DA CRIANAA criana est matriculada em alguma unidade bsica de sade? Sim ( ) No ( )
Qual?_________________________________________________________________________________
Possui convnio mdico? Sim ( ) No ( )Qual? _________________________________________________________________________________
Freqenta alguma escola ou freqentou? Sim ( ) No ( )
Qual? _________________________________________________________________________________
III ANTECEDENTES GESTACIONAIS E NEONATAISHavia doena preexistente da me antes da gravidez? Sim ( ) No ( )Qual?_________________________________________________________________________________
Fez pr-natal? Sim( ) No( )
Durante a gravidez adquiriu alguma doena? Sim ( ) No ( )
Qual?_________________________________________________________________________________
Fez tratamento? Sim( ) No( )
Usou medicamento (s)? Sim( ) No( )
Qual(is)? _______________________________________________________________________________Local onde a criana nasceu:_______________________________________________________________PARTO
( ) normal
( ) cesariana
( ) frceps
NASCEU A
( ) termo
( ) Pr-termo
( ) Ps-termo
AO NASCER
( ) chorou logo
( ) demorou pra chorar
Apgar ______ / _______
Peso:_______________ Altura:________________Fototerapia? Sim( ) No ( )Houve problemas na hora do nascimento? Sim ( ) No ( )
Qual(is)________________________________________________________________________________
Quando a me recebeu alta da maternidade, o RN tambm recebeu? Sim ( ) No ( )
Porque no? ____________________________________________________________________________
O RN ao nascer ficou em:
( ) berrio
( ) alojamento conjunto
( ) enfermaria comum
( ) UTI peditrica
( ) Nasceu em casa
Realizou o teste do pezinho ? ____________________________________________________________
A criana possui alguma doena gentica, seqela de doena, trauma ou outra doena especfica?
( ) Sim ( ) No ( ) Em investigao
Qual (is)? ______________________________________________________________________________
Faz acompanhamento? ( ) Sim ( ) No
Onde? _________________________________________________________________________________A me amamentou? ( ) Sim ( ) No
Durante quanto tempo? ___________________________________________________________________
IV DESENVOLVIMENTOSorriu aos ___________meses
Sustentou a cabea com ___________________________________________________________________Sentou com ____________________________________________________________________________Engatinhou com ________________________________________________________________________Andou com ____________________________________________________________________________Falou com _____________________________________________________________________________Dentio aos ___________________________________________________________________________Controla esfncteres? ( ) Sim ( ) No
Usa chupeta? ( ) Sim ( ) No
Enurese? ( ) Sim ( ) No
Encoprese? ( ) Sim ( ) No
Usa mamadeira ( ) Sim ( ) No
Alimenta-se sozinho ( ) Sim ( ) NoToma banho sozinho ( ) Sim ( ) No
Veste-se sozinho ( ) Sim ( ) No
Sono: ( ) Agitado ( ) Tranqilo ( ) Fala dormindo ( ) Sonambulismo V IMUNIZAO ( vacinao )Completa ( ) Incompleta ( )
Vacinas especiais? ( ) Sim ( ) No
Qual (is)? ______________________________________________________________________________VI DISTRBIOSViso ( ) _______________________________________________________________________
Audio ( ) __________________________________________________________________________
Fala ( linguagem) ( ) _________________________________________________________________
Motor ( ) ______________________________________________________________________________
Neurolgico ( ) _________________________________________________________________________
Psicolgico ( ) _________________________________________________________________________
Endocrinolgico ( ) __________________________________________________________________
Sindrmico ( ) ________________________________________________________________________
Aprendizagem ( ) ____________________________________________________________________
Outros? _______________________________________________________________________
Quais? _______________________________________________________________________Faz uso de medicamento(s) atualmente?
Qual(is)? _______________________________________________________________________
VII DOENAS PRPRIAS DA INFNCIA( ) catapora ( ) hepatite ( ) rubola ( ) caxumba ( ) meningite ( ) encefalite
( ) pneumonia ( ) rinite ( ) outras
Quais ? ______________________________________________VIII HISTRICO PREGRESSO DA CRIANA
Internaes? ( ) Sim ( ) No Quantas? _____________________________________________
Porque?________________________________________________________________________________ Cirurgias? ( ) Sim ( ) No Quais? _______________________________________________
______________________________________________________________________________________
Fraturas? ( ) Sim ( ) No Onde e motivo? ________________________________________
Possui alergia a algum tipo de medicamento(s) ou substncia(s) ( ) Sim ( ) NoQual (is) _______________________________________________________________________________
Usa culos? ( ) Sim ( ) No _________________________________________________________Usa prtese auditiva? ( ) Sim ( ) No ___________________________________________________
IX HISTRICO ATUAL DA CRIANAFaz acompanhamento mdico ou no mdico:
Neurolgico( ) _____________________________________________________________________
Oftalmolgico( ) _____________________________________________________________________
Ortopdico ( ) _____________________________________________________________________
Psiquitrico( ) _____________________________________________________________________
Otorrinolaringolgico( ) ________________________________________________________________
Psicolgico ( ) _____________________________________________________________________
Odontolgico( ) _____________________________________________________________________
Fonoaudiolgico( ) _____________________________________________________________________
Fisioterpico( ) _____________________________________________________________________
Pedaggico ( ) _____________________________________________________________________
Outros: _____________________________________________________________________ X OBSERVAES E CONDUTAS_____________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________ ____________________________________ Professor Sala multifuncional Entrevistador