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ANAMNESE e ACOLHIMENTO

IDENTIFICAÇÃO PESSOAL
Nome:_________________________________________________________________________________ Idade: ______
DN: ___/___/____ Sexo: Feminino Masculino

Pai: _________________________________________________________________________________________________

Mãe: _______________________________________________________________________________________________

Plano de Saúde: _____________________reembolso ( ) sim ( ) não - Co-participação ( ) sim ( ) não

Residência: _______________________________________________________ N. ________

Bairro:_______________ Cidade: ________________ Fones:_______________________________________________


Informante: ____________________________________ Data do Exame: ____/____/_____
Encaminhado por: __________________________________________________________________________________

DIAGNÓSTICO: ____________________________________________________________________________________

Medicação Atual:____________________________________________________________________________________

Médico Responsável:________________________________________________________________________________

QUEIXA OU MOTIVO DA CONSULTA:


______________________________________________________________________________________________________
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HISTÓRIA DA MOLÉSTIA ATUAL:

ANTECEDENTES PESSOAIS
História da Gestação (idade, planejada, pré-natal, uso de drogas, medicamentos, ameaça de
aborto, dieta, intercorrências):

Pré maturo: _________________________________________________________________________________________


Parto (tipo, idade gestacional, peso, cor, choro, Apgar, intercorrências):
______________________________________________________________________________________________________
______________________________________________________________________________________________________
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Período Neonatal (choro, icterícia, convulsões, sucção)


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HISTÓRIA DA MOLESTIA PREGRESSA


Tratamentos Anteriores (médicos, reabilitação, exames):
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________

Internações(infecção,cirurgias):_____________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________

Antecedentes alérgicos:____________________________________________________________________________

Uso de órteses:
______________________________________________________________________________________________________
______________________________________________________________________________________________________

Locomoção:
______________________________________________________________________________________________________
______________________________________________________________________________________________________

Escola:
______________________________________________________________________________________________________
______________________________________________________________________________________________________

Horas de sono e qualidade do sono


( ) 7-9 h

( ) mais de 9h

( ) 4-6 h

( ) menos de 4 h

( ) Diagnosticado com distúrbio de sono

( ) Dificuldade em adormecer

( ) Acorda muito cedo


( ) Dificuldade em voltar a dormir, caso acorde de madrugada

( ) Muita dificuldade para acordar

Sonda:
( ) Traqueal

( ) Nasogástrica

( ) Vesical

( ) Gastrostomia

Apetite:
( ) Pouco apetite

( ) Excessivo apetite

( ) Compulsivo

COPM – MEDIDA CANADENSE DE DESEMPENHO OCUPACIONAL (questionário anexo)


Data avaliação: _____/_____/_______
Entrevistado: _____________________________________________________________

Problemas Importância Desempenho Satisfação


1.
2.
3.

Obs:
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Encaminhamento para:

( ) Fisioterapeuta motor
( ) Fisioterapeuta respiratório
( ) Terapeuta Ocupacional
( ) Fonoaudiólogo
( ) Psicopedagogo - Neuropedagogo
( ) Psicólogo
( ) Nutricionista
( ) Neuropediatra
( ) Ortopedista
( ) Musicoterapeuta

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