ANAMNESE INFANTIL - TERAPIA OCUPACIONAL

Prévia do material em texto

Terapia Ocupacional 
Anamnese Infantil 
 
Identificação 
Nome: _____________________________________________ 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 Pregressa 
Gravidez (idade, planejada, pré-natal, uso de drogas, medicamentos, ameaça de aborto, dieta, 
intercorrências): _________________________________________________________________ 
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________ 
Parto (tipo, idade gestacional, peso, cor, choro, intercorrências): __________________________ 
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________ 
Período Neonatal (choro, icterícia, convulsões, sucção, movimentação): ____________________ 
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________ 
Tratamentos anteriores (médicos, reabilitação, exames): ________________________________ 
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________ 
Internações (infecção, cirurgias): ___________________________________________________ 
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________ 
Vacinas: _______________________________________________________________________ 
Antecedentes alérgicos: __________________________________________________________ 
 
História Desenvolvimento 
Controlou cabeça: _______________________________________________________________ 
Rolou: ________________________________________________________________________ 
Arrastou: ______________________________________________________________________ 
Sentou: _______________________________________________________________________ 
Engatinhou: ____________________________________________________________________ 
Andou: ________________________________________________________________________ 
Falou: ________________________________________________________________________ 
Esfíncteres: ____________________________________________________________________ 
 
Rotina da Criança 
Com que / onde fica a criança: _____________________________________________________ 
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________ 
Relacionamento familiar: __________________________________________________________ 
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________ 
 
Assiste TV (posição, tempo, programa): ______________________________________________ 
______________________________________________________________________________
Gosta de música (preferência,como reage): ___________________________________________ 
______________________________________________________________________________ 
Passeios, locais que freqüência: ____________________________________________________ 
______________________________________________________________________________ 
Brincar (como, posição, tempo, nível de atenção, brinquedos preferidos): ___________________ 
______________________________________________________________________________ 
______________________________________________________________________________ 
______________________________________________________________________________ 
______________________________________________________________________________ 
______________________________________________________________________________ 
______________________________________________________________________________ 
______________________________________________________________________________ 
______________________________________________________________________________ 
 
Escola 
Nome, 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: ____________________________________________________________________ 
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________ 
Higiene: _______________________________________________________________________ 
____________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________ 
Banho: ________________________________________________________________________ 
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________ 
Vestir: _________________________________________________________________________ 
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________ 
Despir: ________________________________________________________________________ 
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________ 
 
Observações: ___________________________________________________________________ 
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________ 
______________________________________________________________________________ 
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________ 
 
 
 
____________________________________ 
Terapeuta Ocupacional