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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