Consultório de Psicologia

ANAMNESE PARA CRIANÇA

Data_____/_____/_____

1 – IDENTIFICAÇÃO

Nome:____________________________________________________________________

Data Nascimento_____/_____/_____ Idade:______________ Sexo:___________________

Grau de Escolaridade________________________________________________________

Escola:______________________________________ Período:______________________

Pai:________________________________________________ Idade:_________________

Profissão:______________________________ Nacionalidade:_______________________

Mãe:________________________________________________ Idade:________________

Profissão:______________________________ Nacionalidade:_______________________

GENETOGRAMA

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Outras pessoas residentes na casa:_____________________________________________
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Queixa:___________________________________________________________________
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2 – ANTECEDENTES FAMILIARES

Pai e família:_______________________________________________________________
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Mãe e família:______________________________________________________________
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Irmãos:____________________________________________________________________
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3- ANTECENDENTES PESSOAIS

A- GESTAÇÃO
Pré-Natal:__________________________________________________________________
Doenças: __________________________________________________________________
Medicamentos: _____________________________________________________________
Traumatismos: _____________________________________________________________
Duração de Gravidez: _______________________________________________________
Fator Rh: _______________________ Radioterapia:_______________________________
B- PARTO

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Natural ( ) Induzido ( ) Fórceps ( ) Cesariana ( )

Anestesia: ____________________ Sinal de trauma: ______________________________

Peso: _______________________ Comprimento do bebê: _________________________
Chorou logo: ______________________________________________________________
Observações: ______________________________________________________________

C- ALIMENTAÇÃO
1- Alimentação Natural
Mamou logo: _____________________ Até quando: _______________________________
Por quê? __________________________________________________________________
Sucção e deglutição na época: _________________________________________________
Outras Informações: _________________________________________________________
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2- MAMADEIRA: ______________________ Período: _____________________________

Tipo de bico: ______________________ Aumentou o furo: __________________________
Colher ( ) Copo ( ) Canudo ( ) Problemas: ____________________________
Alimentos Sólidos: __________________________________________________________
Outras Informações: _________________________________________________________
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3- ALIMENTAÇÃO ATUAL
Come bem? ____________________ Rápido ou devagar? __________________________
Mastiga muito ou pouco? _____________________________________________________

4- DENTES
Escova os dentes? ________ Freqüência de consulta ao dentista:_____________________
Problemas dentários: ________________________________________________________
Hábitos de sucção (chupeta, dedo, lábio): ________________________________________
Roe unhas?_________________ Baba ou escorre saliva? ___________________________

D- SAÚDE
Doenças: __________________________________________________________________

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Medicamentos: _____________________________________________________________
Amigdala: ________________________ Adenóide: ________________________________
Alergia: _______________________ Respiração ruidosa: ___________________________
Obstrução nasal: ____________________________________________________________
Exame Otorrinolaringológico: __________________________________________________
Problemas visuais: __________________________________________________________

E- DESENVOLVIMENTO MOTOR

Firmou a cabeça: __________________ Sentou sozinho: ___________________________

Engatinhou: ___________________ Ficou de pé : _________________________________
Andou sozinho: _____________________________________________________________
Controle esfincteriano: _______________________________________________________
Não usada: ________________________________________________________________

F- DESENVOLVIMENTO NA LINGUAGEM

1- as palavras: ____________________________________________________________
1- as frases: ______________________________________________________________
É entendido ao falar? ________________________ Gagueira: ______________________

G- DESENVOLVIMENTO AUDITIVO

Reação a sons: ____________________________________________________________

Problema auditivo: Otalgia ( ) Otorréia ( )
Observação: ______________________________________________________________
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4- SOCIABILIDADE

Relacionamento com crianças: _______________________________________________

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Relacionamento com os pais: ________________________________________________
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Relacionamento com os irmãos:______________________________________________

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LAUDO:___________________________________________________CID10:__________
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RELATÓRIO:_______________________________________________________________
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Data Inicial do Tratamento___/____/___ Data de Interrupção do tratamento: ____/____/___

Motivo:____________________________________________________________________
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Profissional:_________________________________________CRP: __________________

Nome do Paciente:__________________________________________________________

Assinatura do Paciente: ______________________________________________________

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TRATAMENTO

Evolução Clínica: ___________________________________________________________

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