Шрифт:
Возраст .................................... Дата рождения ..........................
Первое обследование ............................................................................
Второе обследование .............................................................................
Третье обследование ...............................................................................
Для заметок лечебного педагога
1. Предыстория (анамнез): ..................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
2. Причина представления:.................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
3. Наблюдения специалиста,
проводившего обследования
Контакты с другими лицами: ..............................................................
.................................................................................................................................
Поведение в игре: ......................................................................................
.................................................................................................................................
Особые замечания:...................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
4. Диагноз: .......................................................................................................
.................................................................................................................................