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Anamnese infantil

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Anamnese infantil

  1. 1. Terapia Ocupacional Anamnese InfantilIdentificaçãoNome: _____________________________________________ Data da Avaliação: ___/___/____Data Nasc: _____/_____/______ Idade:_____ Sexo: ____ Naturalidade: ___________________Escolaridade: ___________________________________________________________________Filiação: Pai: __________________________________________________ Idade: ___/___/____ Profissão: _______________________________ Escolaridade: ___________________ Mãe: _________________________________________________ Idade: ___/___/____ Profissão: _______________________________ Escolaridade: ___________________Responsável: ___________________________________________________________________Endereço: _____________________________________________________________________Telefone: ____________________Cidade: __________________Estado: __________________Diagnóstico / Seqüela: ___________________________________________________________Medicação atual: ________________________________________________________________Médico responsável: _____________________________________________________________Encaminhamento: _______________________________________________________________Composição familiar: _________________________________________________________________________________________________________________________________________________________________________________________________________________________Queixa principal: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________História PregressaGravidez (idade, planejada, pré-natal, uso de drogas, medicamentos, ameaça de aborto, dieta,intercorrências): _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Parto (tipo, idade gestacional, peso, cor, choro, intercorrências): __________________________
  2. 2. __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Período Neonatal (choro, icterícia, convulsões, sucção, movimentação): ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Tratamentos anteriores (médicos, reabilitação, exames): __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Internações (infecção, cirurgias): _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Vacinas: _______________________________________________________________________Antecedentes alérgicos: __________________________________________________________História DesenvolvimentoControlou cabeça: _______________________________________________________________Rolou: ________________________________________________________________________Arrastou: ______________________________________________________________________Sentou: _______________________________________________________________________Engatinhou: ____________________________________________________________________Andou: ________________________________________________________________________Falou: ________________________________________________________________________Esfíncteres: ____________________________________________________________________Rotina da CriançaCom que / onde fica a criança: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Relacionamento familiar: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
  3. 3. Assiste TV (posição, tempo, programa): ____________________________________________________________________________________________________________________________Gosta de música (preferência,como reage): _________________________________________________________________________________________________________________________Passeios, locais que freqüência: __________________________________________________________________________________________________________________________________Brincar (como, posição, tempo, nível de atenção, brinquedos preferidos): ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________EscolaNome, horário, série: _____________________________________________________________Relacionamento c/ profª: __________________________________________________________Relacionamento c/ colegas: _________________________________________________________Mobiliário: ______________________________________________________________________Dificuldades: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Comportamento (humor, birras, medos):___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Atividades de Vida Diária (posição, local, dificuldades, nível de dependência)Alimentação: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
  4. 4. Higiene: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Banho: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Vestir: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Despir: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Observações: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________ Terapeuta Ocupacional

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