Terapia OcupacionalAnamnese Infantil

IdentificaçãoNome: _____________________________________________ 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: _____________________________________________________________

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Queixa principal: ________________________________________________________________

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História PregressaGravidez (idade, planejada, pré-natal, uso de drogas, medicamentos, ameaça de aborto, dieta,

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, exames): ________________________________

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Internações (infecção, cirurgias): ___________________________________________________

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Vacinas: _______________________________________________________________________

Antecedentes alérgicos: __________________________________________________________

História DesenvolvimentoControlou cabeça: _______________________________________________________________

Rolou: ________________________________________________________________________

Arrastou: ______________________________________________________________________

Sentou: _______________________________________________________________________

Engatinhou: ____________________________________________________________________

Andou: ________________________________________________________________________

Falou: ________________________________________________________________________

Esfíncteres: ____________________________________________________________________

Rotina da CriançaCom que / onde fica a criança: _____________________________________________________

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Relacionamento familiar: __________________________________________________________

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Assiste TV (posição, tempo, programa): ______________________________________________

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Gosta de música (preferência,como reage): ___________________________________________

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Passeios, locais que freqüência: ____________________________________________________

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Brincar (como, posição, tempo, nível de atenção, brinquedos preferidos): ___________________

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EscolaNome, horário, série: _____________________________________________________________

Relacionamento c/ profª: __________________________________________________________

Relacionamento c/ colegas: _________________________________________________________

Mobiliário: ______________________________________________________________________

Dificuldades: ____________________________________________________________________

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Comportamento (humor, birras,

medos):_________________________________________________

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Atividades de Vida Diária (posição, local, dificuldades, nível de dependência)

Alimentação: ____________________________________________________________________

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Higiene: _______________________________________________________________________

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Banho: ________________________________________________________________________

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Vestir: _________________________________________________________________________

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Despir: ________________________________________________________________________

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Observações: ___________________________________________________________________

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Terapeuta Ocupacional