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CAPSi Juazeiro - Ba
Paciente:__________________________________
D.N.:____/___/_____ Idade:__________________
Escola:_______________________ Srie:________
Responsvel________________________________
Telefones: Fixo__-_________ Cel: ___-___________
Sesso
Data
Atividade
1
2
3
Provas Operatrias:
Tcnicas Projetivas:
Provas pedaggicas: conscincia fonolgica, lateralidade, coordenao visomotora, orientao temporal, jogos, Anlise do material escolar , etc.
7
8
Anamnese
Devoluo / Encaminhamento
Obs: Abordagens aplicadas podem variar de acordo com a complexidade do caso, bem
como o numero de sesses.
Observao:___________________________________
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Observao:___________________________________
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Observao:______________________________
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Concluso da EOCA:
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PROVAS OPERATRIAS
PROCEDIMENTOS E 1
RESULTADOS MODIF.
2
MODIFIC.
3
MODIFIC.
NVEL
ARGUMENTOS UTILIZADOS
CONSERVAO
OPERATORIO
CONCRETO
OBSERVAES
C NC
NC C
NC
1,2, Ou
3
Seriao
Dicotomia
Incluso de Classe
Interseco de
Classes.
TCNICAS PROJETIVAS
Eu com meus companheiros:
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Par Educativo:
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Famlia Educativa:
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( ) Canhoto
( ) No
( ) No
( ) No
( ) No
No ( )
( ) No
Observao:_______________________________________________________________________________________
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Avaliao Lateralidade.
Mostra a mo direita: ( )Sim
( ) No
( ) No
( ) No
( )Esquerdo
( ) Esquerda
( ) No
b e d ( ) Sim
( ) No
( ) No
( ) No
( ) No
Avaliao Temporal
Se hoje quarta-feira, quantos dias faltam para chegar sbado? Resp.______________________________________
Se hoje segunda, quantos dias faltam para chegar domingo? Resp.________________________________________
Que horas voc toma caf ? Resp.____________________________________________________________________
Que horas voc janta? Resp.________________________________________________________________________
Que horas voc acorda pela manh? Resp._____________________________________________________________
Que horas voc vai dormir? Resp._____________________________________________________________________
Quais os dias da semana?___________________________________________________________________________
Quais os meses do ano?____________________________________________________________________________
( ) Sim
( ) No
Perto:
( ) Sim
( ) No
Em cima: ( )Sim
( ) No
Em baixo:
( )Sim
( )No
Atrs:
( )Sim
( )No
Em frente:
( ) Sim
( )No
Maior:
( )Sim
( )No
Menor:
( ) Sim
( )No
Alto:
( )Sim
( )No
Baixo:
( ) Sim
( )No
( )No
( )No
( )No
( ) Sim
( )No
( ) No
( )No
Anamnese
1 CONCEPO
- Qual a condio do casal quando a criana foi concebida:
Casados ( ) noivos ( ) namorando ( ) morando juntos ( )
- Idade dos pais na poca: pai (
) me (
2 GESTAO
- Acompanhamento pr natal ? ______________________________________________________________
- ingesto de algum tipo de drogas? Lcitas e inlcitas? ____________________________________________
- Quedas ou acidentes durante? ______________________________________________________________
- Doenas: rubola
( ) No
sfilis ( )Sim
( )No
- Condies emocionais?____________________________________________________________________
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3 - PARTO
- Nasceu com quantos kg?_____________________________
- Tipo de parto? _____________________________________
- Como foi o parto? (sofrimento fetal, m oxigenao, leses, ) _____________________________________
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4 - HISTRIA CLNICA
- Bronquite?______________________________________________________________________
- Alergia? ________________________________________________________________________
- Viroses prprias da infncia ? ______________________________________________________
- Internaes ? ____________________________________________________________________
- Intervenes cirrgicas ? ____________________________________________________________
-Outras doenas tratamentos realizados (fonoaudilogo, psiclogo....)___________________________
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- Problemas de viso/audio?___________________________________________________________
e como foi?___________________________________________________
Atraso na linguagem:_____________________________________________________________________
HOJE:
- Troca letras ?_________________________________________________________________________
- Fala muito / pouco (ansioso)? __________________________________________________________
- Fala de uma forma que todos entendem ? D um exemplo de como ele(a) fala Consegue dar um recado ?
______________________________________________________________________________________Faz uma compra sozinho(a)? __________________________________________________________
- Como conta uma histria / um caso / uma novela ? D um exemplo:
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- Voc entende o que ele(a) conta ? Tem comeo, meio e fim ?
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6 - HISTRIA ESCOLAR:
- Frequentou creches ?________________ - Idade que entrou para a escola :?_______________________
- Quem escolheu a escola ? ___________________- Como foi essa escolha ?_______________________
- Caso tenha havido mudana, por que mudou ? _______________________________________________
- Repetiu de ano ?__________________ - Por que ?____________________________________________
- Houve problema com professor (es) ?_______________________________________________________
- O que voc acha da escola? __________________ -h uma abertura, um dilogo?___________________
7- ESTIMULAO :
- A criana tem acesso a: brinquedos pedaggicos:
( )jogos ( ) Revistas ( )livros ( )brinquedos
eletrnicos ?
- De que atividades ele(a) participa: ( )musica ( )dana
( )esporte
- Como a criana brinca: ( )Sozinha ( ) Com os amiguinhos ( ) S meninas
( ) Misto
- Tem muitos brinquedos_____________ Tem cimes de seus brinquedos?________________________
- organizada?________________________________________________________________________
- Que tipos de brincadeiras ou brinquedos gostava mais quando tinha, por exemplo 2 anos, 4 anos, 6
anos, etc._________________________________________________________________________
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Informe Psicopedaggico
Nome_____________________________________________________________
Data de Nascimento:____/_____/_______
Idade na Avaliao:___________________
Perodo de avaliao:________________________________
Escola:___________________________________________________ Srie:______________________
Motivo da Avaliao:_______________________________________________________________________
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Instrumentos Utilizados:
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Aspectos Cognitivos:
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Aspectos Pedaggicos:
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Aspectos Orgnicos:
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Aspecto afetivo-Social
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Prognstico / orientaes/ Encaminhamentos.
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