ANAMNESE DE OFA

I-Identificação:
Nome: ____________________________________________________________Cat.: ______________ Nº ________
Data de nasc.: ______ / ______ / ______ Idade: __________ Data da avaliação: _____ / _____ / _____
Endereço: ________________________________________________ Bairro: ________________________________
Escolaridade: ______________________________________________Telefone: ______________________________
Nome da mãe: _______________________________________ Profissão: ___________________________________
Nome do pai: ________________________________________ Profissão: ___________________________________
II-Relato do problema:
Descrição: ______________________________________________________________________________________
Encaminhamento: ________________________________________________________________________________
Parentes com o mesmo problema: ____________________________________________________________________
III-Desenvolvimento:
Gestação: _______________________________________________________________________________________
Parto: __________________________________________________________________________________________
Motor: _________________________________________________________________________________________
Fala e linguagem: ________________________________________________________________________________
Escola: _________________________________________________________________________________________
IV-Alimentação:
Amamentação: ___________________________________________________________________________________
Papas e sólidos: __________________________________________________________________________________
RGE: __________________________________________________________________________________________
Tipo de alimentação: ______________________________________________________________________________
Líquidos: _______________________________________________________________________________________
V-Hábitos:
Chupeta: ________________________________________________________________________________________
Dedo: __________________________________________________________________________________________
Mamadeira: _____________________________________________________________________________________
Outra sucção: ____________________________________________________________________________________
Morde bochechas ou lábios: ________________________________________________________________________
Rói unhas: ______________________________________________________________________________________
Baba ou salivação em excesso: ______________________________________________________________________
Come rápido: ____________________________________________________________________________________
Bruxismo: ______________________________________________________________________________________
Ronco: _________________________________________________________________________________________
Enurese noturna: _________________________________________________________________________________
Sono: __________________________________________________________________________________________
Cospe ao falar: ___________________________________________________________________________________
Mau hálito: ______________________________________________________________________________________
VI-Histórico Médico:
Doenças: _______________________________________________________________________________________
Acidentes: ______________________________________________________________________________________
Cirurgia: ________________________________________________________________________________________
Dentista: ________________________________________________________________________________________
Tratamentos: ____________________________________________________________________________________
Medicações: _____________________________________________________________________________________
Alergias: _______________________________________________________________________________________
Amigdalites: ____________________________________________________________________________________
Adenóides: ______________________________________________________________________________________
Otites: _________________________________________________________________________________________
VII-Socialização:
Família: _________________________________________________________________________________________________
Outros: _________________________________________________________________________________________
VIII-Observações: _______________________________________________________________________________
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 AVALIAÇÃO DE OFA

Nome: ____________________________________________________________Cat.: ______________ Nº ________

Data de nasc.: ______ / ______ / ______ Idade: __________ Data da avaliação: _____ / _____ / _____

I-Diagnóstico Ortodôntico:
Aparelho: _______________________________________________________________________________________
Mordida: _______________________________________________________________________________________
Outros: _________________________________________________________________________________________

II-Anatomia
1-Face: 5-Lábios 8-Palato Mole
( ) Assimetria ( ) Ocluídos ( ) Curto
( ) Olheiras ( ) Separados ( ) Úvula
( ) Normal ( ) Hipotônicos ( ) Normal
2-Mandíbula ( ) Hipertônicos 9-Dentes
( ) Abaixada ( ) Evertidos ( ) Permanente
( ) Retraída ( ) Ressecados ( ) Decídua
( ) Protruída ( ) Normotonia ( ) Mista
( ) Normal 6-ATM 10-Língua
3-Mentális ( ) Estalos ( ) Hipertônica
( ) Tensão ( ) Dor ( ) Hipotônica
( ) Normal ( ) Normal ( ) Geográfica
4- Bochechas 7-Palato Duro ( ) Assoalho
( ) Hipotônica ( ) Ogiva ( ) Papila
( ) Hipertônica ( ) Normal ( ) Freio curto
( ) Normotônica ( ) Outros ( ) Freio Longo

III-Propriocepção:
Interna: _________________________________________________________________________________________
Externa: ________________________________________________________________________________________

IV-Mobilidade e motricidade:
1-Lábios 2-Língua 3-Bochechas
( ) Protrusão / retração ( ) Vibrar ( ) Inflar uma
( ) Protrusão lateralizada ( ) Estalar ( ) Inflar ambas
( ) Beijo ( ) Estalar com bico e risada ( ) Inflar vestíbulo
( ) Beijo de velha ( ) Sugar
( ) Sopro ( ) Pontos cardeais 5-Palato Mole
( ) Vibração ( ) Canelar ( ) Sopro com espelho
4-Mandíbula ( ) Varrer ( ) Vogal oral
( ) Lateralizar ( ) Vestíbulo ( ) vogal nasal
( ) Ântero-posterior ( ) Afilar

V- Funções neurovegetativas:
Respiração: _____________________________________________________________________________________

Sucção:
( ) Lábios ( ) Bochechas ( ) coordenação
( ) Projeção de língua ( ) Canudo ( ) Outros: _________________

Mastigação / Mordida
( ) Mov. de cabeça ( ) Masséter ( ) Tipo
( ) Lábios ( ) Mandíbula ( ) Velocidade
( ) Tamanho ( ) Lado ( ) Mentális
( ) Masca ( ) Outros __________________________________________________
Deglutição
( ) Tensão ( ) Projeção de língua ( ) Mov. de cabeça
( ) Sobra ( ) Masséter ( ) Ruído
( ) Engasgo ( ) Outros __________________________________________________

VI-Conclusão: ___________________________________________________________________________________
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VII-Devolutiva: _________________________________________________________________________________
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VIII-Orientações:________________________________________________________________________________
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Assinatura da mãe ou responsável:_______________________________________________________________