ANAMNESE INFANTIL

DADOS DA CRIANÇA

Nome:__________________________________________________________________________________________________

Idade:___________________ Sexo:___________________________ Data de Nascimento:_____________ __________

Nacionalidade:________________________________Naturalidade:___________________________________________

Escolaridade:____________________________________Escola:________________________________________________

DADOS FAMILIARES

Nome da mãe:_________________________________________________________________________________________

Idade:_______________ Estado civil:_______________________________________________________________________

Nacionalidade:_____________________________________Naturalidade:______________________________________

Profissão:________________________________ Escolaridade: ________________________________________________

Local de Trabalho:_____________________________________________________________________________________

Nome do pai:__________________________________________________________________________________________

Idade:_______________ Estado civil:_______________________________________________________________________

Nacionalidade:_____________________________________Naturalidade:______________________________________

Profissão:________________________________ Escolaridade: ________________________________________________

Local de Trabalho:_____________________________________________________________________________________

Tempo de casamento (se for separado, quanto tempo):_________________________________________________

Irmãos: Nome: __________________________________________________________________

Idade:________________________________ Ocupação:______________________________________________________

Nome: _______________________________________________________________________________________________
Idade:_______________________________ Ocupação:_______________________________________________________

Nome: ________________________________________________________________________________________________
Idade:_______________________________ Ocupação:_____________________________________________________

Quantas pessoas moram na casa:_______________________________________________________________________

MOTIVO – QUEIXA - ENCAMINHAMENTO

Queixa principal:________________________________________________________________________________________

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Evolução da queixa: __________________________________________________________________________________

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Efeitos que a queixa causa/e como a criança se sente sobre a queixa:__________________________________

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OBS:____________________________________________________________________________________________________
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GRAVIDEZ

Planejada:_____________________________ Desejada:_____________________________________

Pré-natal:_______________________________________________________________________________________________

Houve complicações: __________________________________________________________________________________

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Condições de saúde da mãe:___________________________________________________________________________

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Uso de medicações durante a gestação:________________________________________________________________

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Exposição a substancias químicas ou raio x:_____________________________________________________________

Dificuldades de se alimentar:___________________________________________________________________________

Abortos antecedentes: _______________________________________________________________________________

OBS:____________________________________________________________________________________________________
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PARTO

Normal ou Cesária:____________________________________________________________________________________

Como foi o parto, teve dificuldades:___________________________________________________________________

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Internação ao nascer: ________________________________________________________________________________

Estado emocional durante a gravidez e após o parto:__________________________________________________

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Quem cuidou do bebe ao nascer:______________________________________________________________________

OBS:____________________________________________________________________________________________________
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DESENVOLVIMENTO DA CRIANÇA

ALIMENTAÇÃO

Mamou no seio:________________________________________________________________________________________

Quando e como foi o desmame:_______________________________________________________________________

Como é a alimentação: _______________________________________________________________________________

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OBS:____________________________________________________________________________________________________
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SONO

Respeita o horário de sono desde bebê: ______________________________________________________________

Como é o sono:______________________________________________________________________________________

Tempo médio de sono:_______________________________________________________________________________

Enurese noturna: ____________________________________________________________________________________

Dorme com quem no quarto: _______________________________________________________________________

OBS:____________________________________________________________________________________________________
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DESENVOLVIMENTO MOTOR

Era um bebe mole ou firme:____________________________________________________________________________

Engatinhou ( se sim, com quantos meses):______________________________________________________________

Andou sozinho aos:___________________________________________________________________________________

Tem um bom senso de direção, esbarra nas coisas:____________________________________________________

É desajeitado, deixa as coisas cair com facilidade: ___________________________________________________

É ágil:_______________________________________________________________________________________________

Esportes:____________________________________________________________________________________________

Controle esfincteriano com quantos anos:___________________________________________________________

Canhoto ou destro: ________________________________________________________________________________

OBS:____________________________________________________________________________________________________
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DESENVOLVIMENTO DA LINGUAGEM

Quando começou a falar:___________________________________________________________________________

Apresentou gagueira:_______________________________________________________________________________

Habilidade em contar fatos:________________________________________________________________________

Tem coerência no discurso:_________________________________________________________________________

Mantem dialogo com outras pessoas:_______________________________________________________________

Costuma falar sozinho:_______________________________________________________________________________

OBS:____________________________________________________________________________________________________
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HISTORICO ESCOLAR

Frequenta escola desde quando: _______________________________________________________________________

Queixa de maus tratos ou bullying na escola:____________________________________________________________

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Dificuldades nos primeiros anos escolares:________________________________________________________________

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Queixa dos professores em relação a conduta, desde quando:___________________________________________

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Houve mudança de escola (se sim, o motivo):__________________________________________________________

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Repetiu :_______________________________________________________________________________________________

Como foi/esta sendo o aprendizado de leitura e escrita:__________________________________________________

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Mantem-se atento as tarefas escolares:__________________________________________________________________

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Dificuldade de memoria:_______________________________________________________________________________

Desempenho escolar:__________________________________________________________________________________

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Interação social: _______________________________________________________________________________________

Apresenta lentidão ou pressa para realizar as tarefas:____________________________________________________

OBS(dificuldades/habilidades/...):_____________________________________________________________________________
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SOCIABILIDADE
Quem cuida:___________________________________________________________________________________________

É sociável:_____________________________________________________________________________________________

Procura estabelecer contato com outras crianças, tem facilidade:______________________________________

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Qual a preferencia na socialização( sexo, idade, pessoa):_______________________________________________

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Com quem brinca:______________________________________________________________________________________

Como reage a brigas;___________________________________________________________________________________

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Como se comporta com adultos:________________________________________________________________________

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Como e o relacionamento com o professor:_____________________________________________________________

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Onde Brinca frequentemente:___________________________________________________________________________

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Sai sem a família: _______________________________________________________________________________________

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Reações ao ambiente: (agressivo, medroso, tímido, etc)__________________________________________________

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Atitudes familiares: _____________________________________________________________________________________

Como reage a frustrações:_____________________________________________________________________________

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Já houve regressão no comportamento:________________________________________________________________

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OBS:____________________________________________________________________________________________________
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HISTÓRICO MÉDICO

Tem alguma má formação:_____________________________________________________________________________

Já teve sarampo, varíola, caxumba,...:__________________________________________________________________

Doenças que já teve ou tem: __________________________________________________________________________

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Sofreu alguma queda ou pancada na cabeça:__________________________________________________________

Distúrbios psicossomático:_______________________________________________________________________________

Fez todas as vacinas:____________________________________________________________________________________

Faz uso de algum medicamento;________________________________________________________________________

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Já fez tratamento psiquiátrico, neurológico:______________________________________________________________

Já fez tratamento oftalmológico:________________________________________________________________________

Já fez tratamento fonoaudiólogo: _______________________________________________________________________

Já fez tratamento psicológico:___________________________________________________________________________

Vai regulamente ao pediatra:___________________________________________________________________________

OBS:____________________________________________________________________________________________________
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ASPECTOS SENSORIAIS (VISÃO E AUDIÇÃO)

Usa óculos, enxerga bem:_______________________________________________________________________________

Teve ou tem problema auditivo:_________________________________________________________________________

Prefere que fala alto, aumenta o volume da tv:__________________________________________________________

Costuma falar muito alto ou muito baixo:________________________________________________________________

Entende bem instruções: _______________________________________________________________________________

OBS:____________________________________________________________________________________________________
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HISTORICO FAMILIAR

Relação com os pais:__________________________________________________________________________________

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Relação com irmãos: ___________________________________________________________________________________

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Impacto ao nascimento de irmãos: _____________________________________________________________________

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Perdas e separações (estranha ficar longe dos responsáveis, ...):_________________________________________

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Como lida com regras, limites em casa:_________________________________________________________________

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OBS:____________________________________________________________________________________________________
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AMBIENTE DOMESTICO

Como é a casa:_______________________________________________________________________________________

Onde gosta de estar e com quem:______________________________________________________________________

Realiza tarefas domesticas:______________________________________________________________________________

Já se mudou: ___________________________________________________________________________________________

OBS:____________________________________________________________________________________________________
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ROTINA

Tem horários regulares:________________________________________________________________________________

Possui independência (o que consegue fazer sozinho e no que precisa de ajuda):________________________

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Qual o horário escolar: _________________________________________________________________________________

Tem atividades extracurriculares:________________________________________________________________________

Quanto tempo tem para fazer tarefas da escola: ________________________________________________________

Quanto tempo tem livre:_______________________________________________________________________________

Qual brinquedo favorito ________________________________________________________________________________

Quanto tempo fica na tv/celular e o que gosta de assistir: _______________________________________________

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Descrição da rotina dos dias de semana e do final de semana:_________________________________________

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OBS:____________________________________________________________________________________________________
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OBSERVAÇÕES ADICIONAIS

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