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Kultur Dokumente
Data: ___/___/___
Nome: ________________________________________________________________
Idade: _______________ Srie: ___________ Sexo: F ( ) M ( )
Escola: _______________________________________________________________
Nome da me: ________________________ Idade: ____ Profisso: ____________
Nome do pai: _________________________ Idade: ____ Profisso: ____________
1. QUEIXA:
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a) Tempo: _________________________________________________________
b) Forma de incio: _________________________________________________
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c) Sintomas principais: ______________________________________________
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d) Antecedentes clnicos: ____________________________________________
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e) Recursos j utilizados:____________________________________________
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2. Em uso de medicao? Qual?
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4. Histria Pessoal:
a) Gestao:
- Famlia participativa? ( ) Sim ( ) No
- Planejado (a)? ( ) Sim ( ) No
- Desejado (a)? ( ) Sim ( ) No
- Tentativa/ Pensamento de aborto? ( ) Sim ( ) No
- Desenvolvimento da gravidez:
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- Tipo de parto:
( ) Normal ( ) Cesrea
5. Infncia:
a) Socializao/amigos:
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b) Brincadeiras:
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c) Agressividade:
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7. Escola:
a) Aprendizagem:
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b) Relacionamento interpessoal:
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8. Sexualidade:
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9. Do que voc, me/pai, se orgulha dele (a)?
10. Caractersticas:
Paciente Obediente Observador Quieto(a) Estpido (a)
Impetuoso (a) Ordeiro(a) Nervoso (a) Brincalho Bagunceiro(a)
Vaidoso (a) Carinhoso (a) Cuidadoso(a) Inquieto (a) Impulsivo(a)
Srio(a) Atento (a) Manipulador (a) Instvel Impositivo(a)
b) Faz com que a criana se sinta especial, melhor do que as outras crianas?
c) exigente, a criana espera que as coisas ocorram sua maneira?
Observaes da psicloga:
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