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Terapia Ocupacional Anamnese Adulto Identificação Nome: _____________________________________________ Data da Avaliação: ___/___/____ Data Nasc: _____/_____/______ Idade:_____ Sexo: ____ Naturalidade: ___________________ Estado Civil: __________________RG: _______________ CPF: _________________________ Escolaridade: __________________ Profissão: _______________Religião: ________________ Endereço: _____________________________________________________________________ Telefone: ____________________Cidade: __________________Estado: __________________ Diagnóstico / Seqüela: ___________________________________________________________ Medicação atual: ________________________________________________________________ Médico responsável: _____________________________________________________________ Encaminhamento: _______________________________________________________________ Co-morbidades: _________________________________________________________________ Responsável/acompanhante: ______________________________________________________ Composição familiar: _____________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ Queixa principal: ________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ História: _______________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ Antecedente familiar: ____________________________________________________________ Tratamentos anteriores / atuais (médicos, reabilitação, exames): __________________________ ____________________________________________________________________________________________________________________________________________________________ Internação/cirurgias: _____________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ História Atual Uso de álcool, cigarro, outros: ______________________________________________________ Sono: _________________________________________________________________________ Atividades atuais: _______________________________________________________________ ______________________________________________________________________________ Rotina diária: ___________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Relacionamento familiar: __________________________________________________________ ______________________________________________________________________________ Âmbito social (passeio, locais freqüentados, dificuldades): _______________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Atividade de vida diária / Atividade Instrumentais da Vida diária (posição: órteses / adaptações, cadeiras de rodas, dificuldades, outros) Transferências (cadeira de rodas): __________________________________________________ ____________________________________________________________________________________________________________________________________________________________ Higiene (escovas dentes, cabelo, etc.): ______________________________________________ ____________________________________________________________________________________________________________________________________________________________ Continência/Uso do sanitário: ______________________________________________________ ____________________________________________________________________________________________________________________________________________________________ Banho: ________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ Alimentação: ___________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ Vestir-se: ______________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ Atividades domésticas: ___________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ Transporte público: ______________________________________________________________ Dirigir carro: ____________________________________________________________________ Outros: _______________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________ Observações: __________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ _______________________________ Terapeuta Ocupacional
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