Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
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NACIONALIDADE: ___________________________
NATURALIDADE: ____________________________
SEXO: ___________________________
IDADE: _________Anos
BAIRRO:
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TELEFONE: ___________________CELULAR:
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N° DE CÔMODOS: __________________________________________
PAIS:VIVOS OU FALECIDOS:________________________________
GRAU DE INSTRUÇÃO:
PAI:________________________________________________________
MÃE:_______________________________________________________
PROFISSÃO OU OCUPAÇÃO:
PAI:________________________________________________________
MÃE:_______________________________________________________
NACIONALIDADE:
PAI:________________________________________________________
MÃE:_______________________________________________________
IRMÃOS:
NÚMERO:______________________________
IDADE:_____________________________________________________
SEXO:______________________________________________________
VIVOS OU FALECIDOS:______________________________________
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Na Constelação Familiar é
IDADE:____________________
GRAU DE INSTRUÇÃO:______________________________________
OCUPAÇÃO OU PROFISSÃO:_________________________________
NACIONALIDADE:__________________________________________
NATURALIDADE:___________________________________________
TIPO DE UNIÃO:____________________________________________
FILHOS:
NÚMERO:__________________________________________________
IDADE:_____________________________________________________
SEXO:______________________________________________________
VIVOS OU FALECIDOS:______________________________________
MOTIVO DA CONSULTA
- Deixar falar livremente
- O que está acontecendo com senhor(a)?
-Desde quando se sente assim?
- Como começou?
- Teve melhoras ou pioras?
Quando o motivo da consulta é orientação profissional ou educacional,
inclui-se problemas relativos a : Ambições; Interesses; Dificuldades,
etc.
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INFÂNCIA E ADOLESCÊNCIA
VIDA ESCOLAR
VIDA PROFISSIONAL
→Vícios
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VIDA SOCIAL
GOSTOS E INTERESSES
VIDA SEXUAL
CONHECIMENTOS SEXUAIS
MASTURBAÇÃO
DOENÇAS VENÉREAS
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DOENÇAS E ACIDENTES
→Inter-relações
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→Tipo de residência
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ANTECEDENTES MÒRBIDOS
IMPRESSÕES DA PSICÒLOGA
IDENTIFICAÇÃO
NOME:_____________________________________________________
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NACIONALIDADE:___________________________
NATURALIDADE:____________________________
SEXO:___________________________
ESTADO CIVIL:________________________________
GRAU DE INSTRUÇÃO:______________________________________
PROFISSÃO OU OCUPAÇÃO:_________________________________
ENDEREÇO ATUAL:_________________________________________
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BAIRRO:____________________________________________________
TELEFONE:___________________CELULAR:___________________
RESIDÊNCIA PRÓPRIA:_______________________
N° DE CÔMODOS:___________________________________________
CONDUÇÃO DA FAMÍLIA:___________________________________
PAIS VIVOS:________________________________________________
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IDADE PAI:________________SAÚDE:__________________________
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ESTADO CIVIL:_____________________________________________
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IDADE MÃE:________________SAÚDE:_________________________
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ESTADO CIVIL:_____________________________________________
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CONSTELAÇÂO FAMILIAR:_________________________________
IRMÃOS:
NÚMERO:______________________________
IDADE:_____________________________________________________
SEXO:______________________________________________________
ESCOLARIDADE:___________________________________________
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ENSINO_____________________________________________________
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PROFESSORES______________________________________________
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COLEGAS__________________________________________________
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ASPECTOS GERAIS__________________________________________
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PREFERÊNCIAS E AVERSÕES________________________________
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RELACIONAMENTO FAMILIAR
QUANTO TEMPO?___________________________________________
RELACIONAMENTO SEXUAL
MENSTRUAÇÃO____________________________________________
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FISÍCA E INTELECTUALMENTE_____________________________
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EXTERIORIZA OU NÃO?_____________________________________
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IMPRESSÕES DA PSICÒLOGA
IDENTIFICAÇÃO PESSOAL
Nome:_______________________________________________________
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Nacionalidade: _______________________________________________
Sexo: __________________________________
Idade:__________________________________
Residência:__________________________________________________
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Telefone:____________________________ Celular:_________________
Escola:______________________________________________________
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Grau:_______________________________________
Nome da Mãe:________________________________________________
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Nacionalidade:_____________________________ Idade:________Anos
Nível de Instrução:____________________________________________
Nome do Pai:________________________________________________
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Nacionalidade:_____________________________ Idade:________Anos
Nível de Instrução:____________________________________________
Motivo da Consulta
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ANTECEDENTES PESSOAIS
CONCEPÇÃO
Observações:_________________________________________________
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Gestação
Enjoou?______________________Quanto tempo?_________________
Vomitou?_____________________Quanto tempo?__________________
Hemorragias? Quando?________________________________________
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Nervosismo e outros?__________________________________________
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Transfusão de Sangue?________________________________________
Observações:_________________________________________________
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Parto
A termo?______________________ Local?_______________________
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Atendido por:________________________________________________
Tempo de expulsão?___________________________________________
Observações:_________________________________________________
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DESENVOLVIMENTO
Alimentação
Observações:_________________________________________________
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SONO
Dormia tranquilamente?_______________________________________
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Observações:
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DESENVOLVIMENTO MOTOR
Engatinhou?_________________________________________________
Andou Sozinho(a)?____________________________________________
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Observações:_________________________________________________
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DESENVOLVIMENTO DA LINGUAGEM
Sentenças Completas?_________________________________________
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Observações:_________________________________________________
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ESCOLARIDADE
Atitudes tomadas?____________________________________________
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Repetições (motivo)___________________________________________
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Dificuldades em aritmética?____________________________________
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Ajuda recebida:______________________________________________
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Observações:_________________________________________________
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Sociabilidade
Observações:
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Sexualidade
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Diagnósticos e evolução:
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Distúrbios Sensoriais
Visão
Audição
Tem problemas de audição?
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Observações:
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ROTINA DE VIDA
Observações:
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AMBIENTE
Inter-relacionamento familiar:
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Com os irmãos?
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Outros familiares?
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NIVEL SÓCIO-ECONÔMICO
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NIVEL CULTURAL
AMBIENTE MATERIAL
Observações:
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ANTECEDENTES
Houve ou há na família: pessoas nervosas, débeis mentais, com
convulsões, tiques, psicoses, internados, alcoólatras, toxicômanos,
presos, viciados em jogo (grau de parentesco)
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DATA:_______________ HORA:__________
NOME:_____________________________________________________
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* Caso não possa comparecer, favor avisar com antecedência
DATA:_______________ HORA:__________
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* Caso não possa comparecer, favor avisar com antecedência
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* Caso não possa comparecer, favor avisar com antecedência
DATA:_______________ HORA:__________
NOME:_____________________________________________________
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* Caso não possa comparecer, favor avisar com antecedência
ATENDIMENTO EM GRUPO
01/03/07- 8:30hs -Quinta-feira/ Primeiro
Idade de 55 a 80 anos
CONTATOS
N° NOME IDADE TEL CONTATO
1 Hilda Grellet 65 anos 3638-2323
2 Anésia Santos 66 anos 3628-1009
3 Nilda Sumida 55 anos 3627-2893
4 Ireni Sobrinho 3979-6823 9992-4564
5 Leila Santos 74 anos 3624-7561
6 Antonia Costa 57 anos 3624-7821
7 Cacilda Silva 55 anos 3965-6795
8 Sebastiana Lucas 74 anos 3623-8352
9 Maria Bento 71 anos 3902-3012
10 Ana Alves 78 anos 3617-2037
11 Paulina Anzanello 3967-0518
12 Maria Ap. A. Rocha (016) 55 anos 3491-1191
13 Iraci S. Mazarom (016) 55 anos 3726-3864
14 Vera Nandi 69 anos 3625-4788
15 Lourdes Cintra 66 anos 3615-0388
16 Benedita A. Oliveira (016) 67 anos 3945-2690
17 Olga Lana 70 anos 3636-2528
18 Dino Capri 76 anos 3623-1984
19 José Carlos Theodoro 70 anos 3629-1850
20 Maria Liça 75 anos 3620-2063
21 Olga Poletti Furiama 70 anos 3633-1036
22 José Ribeiro 62 anos 9175-0028
23 Maria José Dalossa anos 3617-2037
24 Marli A. Bononi 57 anos 3624-7706
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ATENDIMENTO EM GRUPO
Quarta- Feira - 8:30hs
Idade de 25 a 54 anos
CONTATOS
N° NOME IDADE TEL CONTATO
1 Cirênia 41 anos 3639-7981
2 Andréia de Barros 39 anos 3975-6259 3602-2463
3 Márcia Nassaro 27 anos 3618-1877
4 Tânia Teixeira 44 anos 3966-5087
5 Marina Gomes 39 anos 3622-5674 (Tia)
6 Luciana Barbosa 33 anos 3941-1072
7 Vanessa Oliveira 33 anos 3638-1120
8 Márcia Basso * 32 anos 3969-1516
9 Alessandra Corazza 35 anos 3612-0846
10 Glauco Lima 41 anos 3625-7514
11 André Basso * 39 anos 9205-0949
12 Avani Martins 51 anos 3617-7311
13 Alessandra R. Corazza 35 anos 3612-0346
14 Leda Reginato 52 anos 3625-7246 9723-6940
15 Valdivia Vieira Silva (016) 38 anos 3953-4218 (sogra)
16 Luciana A. Oliveira 26 anos 3917-0179
17 Brenda Mazer (016) 46 anos 3942-1548
18 Rosangela Dias (016 anos 3946-9600 3942-4975
19 Alexandre Dias (016) 28 anos 3946-9600 3942-4975
20 Jane F. Oliveira anos 3976-5016
21 Sueli Watanabe 44 anos 3630-6287
22 Euterpe Simões da Silva 34 anos 3975-6375
23 Maria Ap. N. Monteiro 46 anos 3964-6407 9704-6535
24 Gisele E. G. Bruno 23 anos 3624-9951
25 Maristela Paula Giordano 21 anos 8156-8126
26 Márcia M. do Nascimento 33 anos 9224-0437
27 Maria Ap. Lopes Veloso 42 anos 3919-0248
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