Anamnese Infantil Terapia Ocupacional

ANAMNESE DE TERAPIA OCUPACIONAL - INFANTIL

Identificação

Nome: __________________________________________________________ Data da avaliação: __/__/__
Data de nascimento: ___/___/_____                 Idade: ________                   Sexo: ___________________  
Naturalidade: ____________________        Responsável:_________________________________________
Endereço: _______________________________________________________________________________
Cidade: _____________________ Telefone: ____________________ Celular: ________________________

Diagnóstico/Sequela:  _____________________________________________________________________
Medicação atual: _________________________________________________________________________
Médico responsável: ______________________________________________________________________
Encaminhamento: ________________________________________________________________________
Co-morbidades: __________________________________________________________________________

Composição familiar: ______________________________________________________________________
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Queixa principal: _________________________________________________________________________
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História: ________________________________________________________________________________
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Antecedente familiar: _____________________________________________________________________
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Tratamentos anteriores/atuais (médicos, reabilitação, exames): ___________________________________
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Internações/Cirurgias: _____________________________________________________________________
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História Atual

Gestação
Tempo gestacional: _______________________________________________________________________
Intercorrências: __________________________________________________________________________
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Parto
____ Normal        ____ Cesárea        ____ Forceps        ____ Parto Induzido        ____ Outras alterações:

Coordenação Motora
Global: _________________________________________________________________________________
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Grossa: _________________________________________________________________________________
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Média: _________________________________________________________________________________
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Fina: ___________________________________________________________________________________
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Visomotora: _____________________________________________________________________________
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Unimanual: _____________________________________________________________________________
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Bimanual: _______________________________________________________________________________
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Preensão:

        Palmar simples:        __ MD         __ ME                        Rosca:                __ MD          __ ME
        Cilíndrica:                __ MD         __ ME                        Tríplice:         __ MD           __ ME
        Gancho:                __ MD         __ ME                        Polpa-polpa:        __ MD   __ ME

Dominância: _____________________________________________________________________________

Sensibilidade Tátil

Texturas: _______________________________________________________________________________
Térmica: ________________________________________________________________________________
Profunda: _______________________________________________________________________________
Proprioceptiva: __________________________________________________________________________
Estereognosia: ___________________________________________________________________________

Senso-percepção

Auditiva: ________________________________________________________________________________
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Gustativa: _______________________________________________________________________________
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Olfativa: ________________________________________________________________________________
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Visual: _________________________________________________________________________________
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