Anamnese Infanto – Juvenil

Nome: _________________________________________________________________
Data de Nasc.: ________________
Idade:_____________ Sexo: _____________ Naturalidade:_______________________
Apelido:______________________
End.:
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____________ CEP: __________________ Bairro:______________________________
Cidade/UF:______________________________________________________________
Em caso de emergência ligar para:
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Alérgico: ( ) S ( ) N
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Toma medicação: ( ) S ( ) N_________________________________________________
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Estuda: ( ) S ( ) N
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Série:
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Turno:__________________________________________________________________

Nome da Mãe: ___________________________________________________________

Data de Nasc.: _____________________ Cidade:_______________________________
Telefone: ( ) ____________________________Profissão_________________________
Nome do Pai: ____________________________________________________________
Data de Nasc.: _____________________ Cidade: _______________________________
Telefone: ( ) ___________________________Profissão:_________________________
Irmão (s)/idade:
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Queixa Principal:
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Profissionais que o acompanham:
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Reforçadores em potencial:
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Com quem passa mais tempo:

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Esportes: ( ) S ( ) N
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Verbal: ( ) S ( ) N
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Interage bem: ( ) S ( ) N
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Olha no olho ao ser chamado: ( ) S ( ) N
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Seletividade alimentar: ( ) S ( ) N
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Dorme bem: ( ) S ( ) N
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Brinca com função: ( ) S ( ) N
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Sabe o seu nome: ( ) S ( ) N
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Sabe as vogais: ( ) S ( ) N
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Sabe as cores: ( ) S ( ) N
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Sabe o alfabeto: ( ) S ( ) N
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Sabe os numerais: ( ) S ( ) N
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Sabe o nome dos responsáveis: ( ) S ( ) N
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Resistência com algum material: ( ) S ( ) N
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Atende a comandos: ( ) S ( ) N
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Estereotipia: ( ) S ( ) N
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Ecolalia: ( ) S ( ) N
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Fixação: ( ) S ( ) N
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Dificuldade motora: ( ) S ( ) N
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Identifica as partes do corpo: ( ) S ( ) N
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Sensibilidade: ( ) S ( ) N
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Resistência a algo: ( ) S ( ) N
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Gosta de música: ( ) S ( ) N
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Fala inglês: ( ) S ( ) N
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Nomeia as cores? ( ) S ( ) N
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Nomeia objetos? ( ) S ( ) N
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Identifica Figuras? ( ) S ( ) N
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Assiste desenho animado? ( ) S ( ) N
Quais?
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Nomeia animais? ( ) S ( ) N
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Sabe as emoções? ( ) S ( ) N
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Sabe se expressar? ( ) S ( ) N
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Auto-agressão: ( ) S ( ) N
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Agressivo com os outros: ( ) S ( ) N
Em quais momentos?
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Gosta de animais? ( ) S ( ) N
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Usa Fralda? ( ) S ( ) N
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Em caso de não usar fralda, sabe pedir para ir ao banheiro? ( ) S ( ) N
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Sabe se vestir sozinho? ( ) S ( ) N
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Sabe comer só? ( ) S ( ) N
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É uma criança desastrada? ( ) S ( ) N
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Tem autonomia para fazer o que?
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Tem noção de perigo? ( ) S ( ) N
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Outras observações:
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Gravidez: Tranquila ( ) Planejada ( ) Não Planejada ( ) Desejada ( ) Indesejada ( )

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Alguma medicação na Gravidez? S ( ) N ( )
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Os pais são parentes em algum grau? S ( ) N ( )
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Parto: Cesária ( ) Normal ( ) Alguma intercorrência?
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Perfil da Criança: Agitado ( ) Tranquilo ( ) Inseguro ( ) Impaciente ( )
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Desde quando perceberam algum desvio no desenvolvimento? Quem observou primeiro?
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A criança mamou? S ( ) N ( ) Dificuldade? Por quanto tempo? Algum complemento?
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Usou e ainda usa chupeta, dedo ou mamadeira? S () N ( )
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Engatinhou? S ( ) N ( ) Andou com quantos meses?
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Dorme sozinha? S ( ) N ( )
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A criança começou a balbuciar com que idade?
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Quais as primeiras palavras e a idade?
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O que mais gosta de fazer?
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Dificuldade na parte pedagógica?
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Dificuldade na interação social?
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Realizada com:
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Assinatura/ Carimbo

Endereço: Rua José Fulgêncio de Carvalho Neto

N° 179 sala 102, Aterrado Volta Redonda.
Whatsapp: (24)99933-5163 Telefone: (24)3026-5612
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