Consultório de Terapia Ocupacional – Dra Cristiane Damaso

DATA DA AVALIAÇÃO: ___/___/___

1.0 IDENTIFICAÇÃO:

Nome: ______________________________________________________________________________
Data de Nascimento: ____/___/____
Diagnóstico Clínico: __________________________________________________________________
Diagnóstico Terapêutico Ocupacional:
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2.0 HISTÓRIA CLÍNICA:

2.1Queixa Principal do Paciente: _________________________________________________________

2.2Hábitos de Vida:____________________________________________________________________

2.3 HMA:____________________________________________________________________________
2.4 HMP:____________________________________________________________________________
2.5Antecedentes Pessoais: _____________________________________________________________
2.6Antecedentes Familiares:_____________________________________________________________
2.7 Tratamentos Realizados:_____________________________________________________________

3.0 EXAME CLÍNICO/EDUCACIONAL/ SOCIAL

3.1 ROTINAS:

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3.2 EXAMES COMPLEMENTARES:

( ) Sim ( ) Não Se sim, quais?______________________________________________________

3.3 USA MEDICAMENTOS:

( ) Sim ( ) Não Se sim, quais? ______________________________________________________
 Consultório de Terapia Ocupacional – Dra Cristiane Damaso

3.4 DESCRIÇÃO DO ESTADO DE SAÚDE:

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3.5 DESCRIÇÃO DA QUALIDADE DE VIDA :

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3.6 DESCRIÇÃO DO PERFIL OCUPACIONAL:

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3.7 TESTES ESPECÍFICOS:

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4.0 PLANO TERAPÊUTICO OCUPACIONAL

4.1 OBJETIVOS DE TRATAMENTO

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4.2 RECURSOS TERAPÊUTICOS

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 Consultório de Terapia Ocupacional – Dra Cristiane Damaso

4.3PLANO DE TRATAMENTO
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4.4EVOLUÇÃO (descrever na evolução estado de saúde do paciente, conduta aplicada, resultados

obtidos e eventuais intercorrências)

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