ANAMNESE

DADOS PESSOAIS

Nome do paciente:
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Idade: _____________________ Data de nascimento: _____/ ______/________

Sexo:_______________________. Endereço completo:
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Escolaridade:
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Nome da escola:
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Telefone da
escola:________________________________________________________________
Nome do
pai:______________________________________________________________________
Nome da
mãe:_____________________________________________________________________
Outro responsável:
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Número de contato de um deles:

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MOTIVO QUE LEVOU O PACIENTE OU FAMÍLIA A PROCURAR

PSICOTERAPIA?

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HISTÓRICO MÉDICO E/OU LAUDOS COM DIAGNÓSTICOS:

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Paciente tem alergias?

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Algum problema de saúde?
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Algum diagnóstico?
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Toma alguma medicação? Qual, e a dosagem? Quem recomendou o

remédio e por quê?
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O paciente vai a algum outro especialista com frequência? Qual? E

por quanto tempo?
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NIVEL DE DESENVOLVIMENTO E DEMAIS INFORMAÇÕES:

Com quantos anos fez contato visual?

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Quando começou a andar?
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Quando começou a falar?
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Quando começou a apontar?

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Quando começou a fazer mandos (pedidos)?
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Quando e como ocorreu o desfraldar?

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Vai ao banheiro sozinho? Nesse processo a criança consegue se

limpar sozinha? dá descarga? Lava as mãos adequadamente?
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Dormi sozinho?
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Qual a rotina do sono?
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Apresenta dificuldades para dormir?

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Apresenta dificuldades para acordar?

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Acorda no meio da noite?

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Dorme em outros horários?
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Quando começou a introdução alimentar?
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Como funciona a alimentação da criança atualmente?

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Existe alguma restrição ou seletividade alimentar?
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O paciente responde quando é chamado pelo nome?
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HABILIDADES SOCIAIS:

Como é a relação com os membros familiares?

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Tem irmãos? Como é a relação entre eles?

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Como a criança interage na escola? Explique detalhadamente?

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Qual o tempo de espera do paciente?
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Paciente sabe perder nos jogos e brincadeiras?

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Como é a relação do paciente com regras?

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Por quanto tempo se mantém engajado em atividades e

brincadeiras de grupo?
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Por quanto tempo se mantém engajado em atividades propostas

pela professora?
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Cumprimenta e responde a comprimento de terceiros?

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Interagir com outras crianças? Descreva essa interação.

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Compartilha objetos?
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RELATÓRIO DAS SESSÕES:

Data e horário:
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PLANEJAMENTO DA SESSÃO:
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OBJETIVO DA SESSÃO E HABILIDADES QUE PRETENDO ENSINAR:

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O que foi realizado na sessão?

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Quais as habilidades e atividades a criança conseguiu executar?

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Comportamentos inadequados na sessão:
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Paciente dormiu bem e se alimentou antes da sessão?

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Como a criança se comportou diante das atividades propostas?

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Que habilidades ela apresentou carência?
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A criança consegue seguir instruções coletivas?

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Consegui imitar?
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ANÁLISE FUNCIONAL DA SESSÃO:

ANTECEDENT RESPOSTA CONSCEQUECI REFORÇO EFEITOS
E A

RELATO DA SESSÃO E OUTRAS OBSERVAÇÕES.