AVALIAÇÃO TO PEDIATRIA

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13. Apêndice I
AVALIAÇÃO INFANTIL
TERAPIA OCUPACIONAL
Identificação
Nome: _______________________________________________Data da Avaliação: ___/___/___
Data de Nasc.: ___/___/___ Idade: ____ Sexo: ____ Naturalidade: ________________________
Escolaridade: ___________________________________________________________________
Filiação
Pai: _________________________________________________________________ Idade: ___
Profissão: ___________________________________ Escolaridade: _______________________
Mãe: ________________________________________________________________ Idade: ___
Profissão: ___________________________________ Escolaridade: _______________________
Responsável: ___________________________________________________________________
Endereço: ___________________________________________________________Nº: _______
Complemento: ________________Cidade: ___________________ Estado: _________________
Telefone fixo: (____)__________-_________ Celular: (____)__________-_________
Informações clínicas
Diagnóstico: ____________________________________________________________________
Médico responsável: _____________________________________________________________
Encaminhamento: _______________________________________________________________
Medicações: ___________________________________________________________________
Queixa principal: ________________________________________________________________
História Pregressa
Gravidez (idade, planejada, pré-natal, uso de drogas, medicamentos, ameaça de aborto, dieta, outras intercorrências):
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Parto (tipo, idade gestacional, peso, cor, choro, intercorrências): 
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Período neonatal (choro, icterícia, convulsões, sucção, movimentação):
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Tratamentos anteriores (médicos, reabilitação, exame):
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Internações (infecções, cirúrgicas):
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Vacinas: _______________________________________________________________________
Alergias: ______________________________________________________________________
História do Desenvolvimento
	Controlou a cabeça
	Sim
	Não
	Observações
	Rolou
	
	
	
	Arrastou
	
	
	
	Sentou
	
	
	
	Engatinhou
	
	
	
	Andou
	
	
	
	Falou
	
	
	
	Controle de Esfíncteres
	
	
	
Rotina da criança
Com o quem e onde fica a criança: ______________________________________________________________________________
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Relacionamento familiar:
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Assiste televisão (posição, tempo, programa):
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Música (preferência, como age):
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Passeios, locais que frequenta:
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Brincar (como, posição, tempo, nível de atenção, brinquedos preferidos):
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Escola
Nome da escola: ________________________________________________________________
Relacionamento com os professores:
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Relacionamento com os colegas:
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Mobiliários: ____________________________________________________________________
Dificuldades:
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Comportamento:
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Atividade de Vida Diária
Alimentação:
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Banho: 
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Vestir:
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Observações:
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Terapeuta Ocupacional