ANAMNESE DE DISARTROFONIA ADULTO

1- Dados Gerais:
Nome: __________________________________________________________________
Idade: _________________ D.N: ___/___/______
Ocupao:
_______________________________________________________________
Endereo: _______________________________________________________________
Telefones: _______________________________________________________________
Queixas: ________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Mdico: _________________________________________________________________
Outros profissionais: _______________________________________________________
________________________________________________________________________
2- Histrico
Doenas graves na infncia: __________________________ Com que idade: _________
Acidentes srios: __________________________________________________________
Possui ou j possuiu algum problema motor: ____________________________________
Qual a sua preferncia alimentar: ___________________________________________
Faz quantas refeies por dia: ___________
Possui alguma dificuldade em se alimentar: _________ Qual: ______________________
Com que tipo de alimento: __________________________________________________
3- Histria Mdica:
Doenas: ________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Doenas anteriores: _______________________ H quanto tempo: ________________

Durao: _____________________________ Severidade: ________________________
Seqelas: _______________________________________________________________
Operaes: ________________________ H quanto tempo: _______________________
Durao: _____________________________ Severidade: ________________________
Seqelas: _______________________________________________________________
Hospitalizaes: _____________________ H quanto tempo: ______________________
Durao: _____________________________ Severidade: ________________________
Seqelas: _______________________________________________________________

Observaes:
_______________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________