) S ( ) N Audicao? ( ) S ( ) NProblemaspsicossomaticos (verificar os possiveis deslocamentos e a eventual relacao coma nao aprendizagem):_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________6. HISTORIA DA FAMILIA NUCLEARFatosmarcantes dos pais e irmaos (antes, durante e depois da entrada do pacientecognoscente na familia):______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________6.1. ESTIMULACAO:Acrianca tem acesso a: Brinquedospedagogicos? ( ) S ( )N Jogos? ( ) S ( ) N Revistas? livros? ( ) S ( )N Brinquedos eletronicos? ( ) S ( ) N Tem muitos brinquedos? ( ) S ( ) N Enjoa rapido de alguma novidade? ( ) S ( ) NDeque atividades ele (a) participa:Musica? ( )S ( ) N Danca ? ( ) S ( ) N Esporte? ( ) S ( ) N Qual?_________________________________________________________________________________________________________________6.2. SITUACOES NEGATIVAS VIVENCIADAS PELACRIANCA (atraves de alteracoes familiares)Nascimentode irmaos ( ) S ( )N Mudancas ( ) S ( ) N Desempregos ( ) S ( ) N Separacoes ( ) S ( ) NMortes( ) S ( ) N De quem? _________________________________________________________________________________________ Duracao doluto:__________________________ Comosuperou?________________________________________________________________7. HISTORIA DA FAMILIA AMPLIADAFamilia:(Passado, Presente, Interferencias, Ligacoes, Quadros Patologicos)____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Formade Disciplina:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Atitudedos pais diante da falta de limite do filho (a): _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Comoa crianca reage?_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Temalguem que a protege? ( ) S ( )N Quem? __________________________________________ Como e a protecao?____________________________________________________________________________________________________________________________________Emuito censurada? ( ) S ( ) N Motivo da censura:________________________________________________________________________Relaciona-sebem com: O pai? ( ) S ( ) N A mae?( ) S ( ) N Osirmaos? ( ) S ( )N Parentes? ( ) S ( ) N Ospais sabem ler e escrever? ( ) S ( ) NQuemo auxilia na licao de casa?__________________________________________________________________________________________Problemaque a familia esta passando no momento:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Comoe o ambiente de brincadeira no dia a dia? Quais brincadeiras?_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Qualprefere?__________________________________________________________________________________________________________Comose relaciona com os colegas? ________________________________________________________________________________________Elider? ( ) S ( ) N E ativo ( ) Passivo ( ) Chora nas brincadeiras? ( )S ( ) NQualo programa preferido na TV? __________________________________________________________________________________________Qualperiodo mais assiste? _______________________________ Quantas horas/dia?_________________Tem TV no seu quarto? ( ) S ( ) NAssisteTV durante as refeicoes? ( ) S ( ) NAssuntoou lazer que interessa a crianca: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________8. HISTORIA ESCOLAR: (considerar:entrada precoce ou tardia na escola; trocas constantes de escolas; como se processou a alfabetizacao; dificuldadesda mae para lidar com as exigencias escolares)Frequentoucreches? ( ) S ( ) N Quando entrou para a escola(idade): _______________________Porque?_____________________________________________________________________________________________________________Quemescolheu a escola?________________________________________________________________________________________________Comofoi essa escolha?__________________________________________________________________________________________________Casotenha havido mudanca, por que mudou?_____________________________________________________________________________________________________________________________________________________________________________________________________Repetiuano? ( ) S ( )N Por que? ___________________________________________________________________________________________________________________________________________________________________________________________________________Houveproblema com professor (es) ( ) S ( )NQual? ______________________________________________________________________________________________________________Comoe a atitude em sala de aula?__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Faltamuito a escola? ( ) S ( ) NPorque? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________Fazreforco? ( ) S ( ) N Ele gosta do reforco? ( ) S ( ) N Qual o motivo doreforco?_________________________________________________________________________________________________________________________________________________________O quevoce acha da escola? (ha uma abertura? um dialogo? ou e tradicional?)__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Afilosofia da escola e Tradicional ( ) Comportamentalista ( ) Construtivista ( ) Socio-construtivista ( ) Outros:________________9. FINALIZACAO:O quevoce mais gosta nesse (a) filho (a)?_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________O quevoce nao gosta nele (a)?_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Orientacaoaos Pais:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Observacoes:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Encaminhamento:(Ao assinalar um ou mais itens, preencher abaixo os motivos que apontem asnecessidades).( ) Psicologo ( )Neurologista ( ) Fonoaudiologista ( )Oftalmologista ( ) Otorrinolaringologista ( ) Pediatra( ) outros: ____________________________________________________________________________________________________________Motivos:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Escolio3: Uma copia dessa anamnese deve acompanhar o relatorio deencaminhamento ao