Terapia Ocupacional

Anamnese Adulto

Identificação

Nome: _____________________________________________ Data da Avaliação: ___/___/____

Data Nasc: _____/_____/______ Idade:_____ Sexo: ____ Naturalidade: ___________________
Estado Civil: __________________RG: _______________ CPF: _________________________
Escolaridade: __________________ Profissão: _______________Religião: ________________
Endereço: _____________________________________________________________________
Telefone: ____________________Cidade: __________________Estado: __________________

Diagnóstico / Seqüela: ___________________________________________________________

Medicação atual: ________________________________________________________________
Médico responsável: _____________________________________________________________
Encaminhamento: _______________________________________________________________
Co-morbidades: _________________________________________________________________
Responsável/acompanhante: ______________________________________________________

Composição familiar: _____________________________________________________________

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Queixa principal: ________________________________________________________________

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História: _______________________________________________________________________
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Antecedente familiar: ____________________________________________________________

Tratamentos anteriores / atuais (médicos, reabilitação, exames): __________________________
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Internação/cirurgias: _____________________________________________________________
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História Atual

Uso de álcool, cigarro, outros: ______________________________________________________

Sono: _________________________________________________________________________
Atividades atuais: _______________________________________________________________
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Rotina diária: ___________________________________________________________________
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Relacionamento familiar: __________________________________________________________
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Âmbito social (passeio, locais freqüentados, dificuldades): _______________________________
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Atividade de vida diária / Atividade Instrumentais da Vida diária (posição: órteses /

adaptações, cadeiras de rodas, dificuldades, outros)

Transferências (cadeira de rodas): __________________________________________________

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Higiene (escovas dentes, cabelo, etc.): ______________________________________________
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Continência/Uso do sanitário: ______________________________________________________
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Banho: ________________________________________________________________________
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Alimentação: ___________________________________________________________________
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Vestir-se: ______________________________________________________________________
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Atividades domésticas: ___________________________________________________________

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Transporte público: ______________________________________________________________
Dirigir carro: ____________________________________________________________________

Outros: _______________________________________________________________________
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Observações: __________________________________________________________________
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Terapeuta Ocupacional