ANAMENSE TEA PATA CRIANÇAS E ADOLESCENTES

● IDENTIFICAÇÃO

Nome da criança: ______________________________________________________________

Data de nascimento: ____/_____/_____ Idade: ___________ Sexo: _____________________

Naturalidade: _________________________________________________________________

Filiação: ______________________________________________________________________

Idade :_________ Profissão: ____________________________________________________

Filiação: ______________________________________________________________________

Idade: _________ Profissão: ____________________________________________________

Responsável: __________________________________________________________________

Endereço: ____________________________________________________________________

Telefone: _________________ Cidade: _________________ Estado: _______

Composição familiar:
_____________________________________________________________________________
_____________________________________________________________________________

Diagnóstico: ___________________________________________________________________

Medicação: ___________________________________________________________________

● HISTÓRIA PREGRESSA:

Gravidez (idade, planejada, pré-natal, uso de drogas, medicamentos, aborto, dieta,

intercorrências – queda, susto, momentos de tristeza):
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Período neonatal (choro, icterícia, convulsões, sucção, movimentação):

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Tratamentos Anteriores (médico, cirurgia, medicação, infecção):

_____________________________________________________________________________

Vacinas: ______________________________________________________________________

Alergias:

______________________________________________________________________

● DESENVOLVIMENTO:

Controlou a cabeça: _________________ Rolou: ____________________

Arrastou: ________________________ Sentou: ___________________

Engatinhou: ________________________ Andou:____________________

Falou:
_____________________________________________________________________________
_____________________________________________________________________________

Dentes: ______________________________________________________________________

AVD’s:
_____________________________________________________________________________
_____________________________________________________________________________

Esfíncteres:
_____________________________________________________________________________

● VIDA SOCIAL:

Estuda (onde, quando, acompanhamento individual? relacionamentos):

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Frequenta quais locais – tipo de interação:

_____________________________________________________________________________
_____________________________________________________________________________

Rotina diária:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Relacionamento familiar:

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Brincar:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

● COMPORTAMENTOS:

Agitação motora: _______________________________________________________________

Estereotipia: __________________________________________________________________

Segue instruções: ______________________________________________________________

Contato visual: ________________________________________________________________

Faz imitação? __________________________________________________________________

Agressividade: _________________________________________________________________

Frustração (não): _______________________________________________________________

Busca sensorial (segura, passa, leva a boca objetos):

_____________________________________________________________________________
_____________________________________________________________________________

Restrição sensorial:

_____________________________________________________________________________
_____________________________________________________________________________

Seletividade alimentar:

_____________________________________________________________________________
_____________________________________________________________________________

● QUEIXAS:

Comportamentos-alvo:

_____________________________________________________________________________
_____________________________________________________________________________

Comportamentos adaptativos:

_____________________________________________________________________________
_____________________________________________________________________________
 ● PREFERÊNCIA DE ATENDIMENTO
_____________________________________________________________________
_____________________________________________________________________

● REGISTRO LIVRE

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

__________________________________________

PROFISSIONAL RESPONSÁVEL