ANAMNESE INFANTIL

Nome: ___________________________________________ Data Nasc. ___/____/_____

Idade: ________ Sexo: ________ Escolaridade: ________________________________

Escola: __________________________________________________________________

Fone: ______________ Professora: __________________________________________

Período: _________________ Classe: _________________________________________

Pai: _____________________________________________________________________

Mãe: ____________________________________________________________________

Responsável: _____________________________________________________________

Endereço: ________________________________________________________________

Bairro: ______________________ Cep: ______________Cidade: __________________

Fone: _______________________ Celular: _________________recado: _____________

E-mail: __________________________________________________________________
Informações dos Pais

1. Como se deu o encontro do casal?

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2. Como era a relação do casal quando a criança foi gerada?

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3. A gravidez foi planejada?

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4. Houve algum aborto anterior ou posterior a esta gravidez?

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5. Houve outras gestações? Antes ou depois?

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6. Como é a relação atual do casal?

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 Informação da Criança

1. Como foi seu desenvolvimento intra-uterino?

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2. Após o nascimento, houve algum problema em seu desenvolvimento ou doença

importante?
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3. Chupou chupeta até quantos anos? Como foi a retirada?

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4. Como era seu sono quando era bebê e como é atualmente?

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5. Quando andou, engatinhou? Teve dificuldades?

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5. Com qual idade adquiriu o controle dos esfíncteres? Este controle se manteve?
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6. Como foi a dentição? (inicio e troca)
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7. Quando ocorreu a primeira menstruação (menarca)?

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8. Qual é a sua relação com a escola (professores, colegas, aprendizagem)?

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9. Tem amigos de sua mesma faixa etária?

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10. Como era e como é atualmente a alimentação da criança?

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11. Quais são as brincadeiras prediletas do seu filho (a)?

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12. Mantém atividades paralelas às aulas? Quais?

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13. Como é sua relação familiar?

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14. Descreva um dia da rotina da criança e acrescente atividades realizadas nos finais de
semana:

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 Informações sobre o Atendimento:

1. Queixa Inicial:

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2. Quando foi percebida e por quem?

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3. Houve algum evento anterior que considere relacionado com a queixa?

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4. Quais são as perspectivas atuais da família em relação à queixa e ao tratamento

psicológico?

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Observações Finais:

Diagnóstico:

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Prognóstico:

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Encaminhamento:

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Observação:

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