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: _____________________________________________________________

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Queixa principal: ________________________________________________________________

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História Pregressa
Gravidez (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 Desenvolvimento
Controlou cabeça: _______________________________________________________________
Rolou: ________________________________________________________________________
Arrastou: ______________________________________________________________________
Sentou: _______________________________________________________________________
Engatinhou: ____________________________________________________________________
Andou: ________________________________________________________________________
Falou: ________________________________________________________________________
Esfíncteres: ____________________________________________________________________

Rotina da Criança
Com 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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Escola
Nome, 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)

Não precisa seguir
Alimentação: ____________________________________________________________________
especificamente
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essa ordem ou essas
informações
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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