Modelo anamnese clínica criança

Data do atendimento: __________Anamnese infantil

Identificação:

Nome:___________________________________________________________________

Idade: __________Sexo: _________________ Nacionalidade: ______________________

Estado Civil: ____________________ Data de nasc.:______________________________

Grau de instrução:__________________________________________________________

Profissão:­­­­­­­­­­­­________________________________________________________________

Residência (cidade/estado): __________________________________________________

Telefones para contado: _____________________________________________________

Atendimento:

Frequência:___________________________ Data/hora:___________________________

Queixa Principal:

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Medicamentos:_____________________________________________________________________________________________________________________________________

Histórico Pessoal:

Infância:____________________________________________________________________________________________________________________________________________________________________________________________________________________

Gestação:__________________________________________________________________________________________________________________________________________________________________________________________________________________

Parto:______________________________________________________________________________________________________________________________________________________________________________________________________________________

Rotina_____________________________________________________________________________________________________________________________________________________________________________________________________________________

Brincadeiras:________________________________________________________________________________________________________________________________________________________________________________________________________________

Medos:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Socialização:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Histórico Familiar:

Pai:_______________________________________________________________________________________________________________________________________________________________________________________________________________________

Mãe:_______________________________________________________________________________________________________________________________________________________________________________________________________________________

Leite materno (até quando):__________________________________________________

Irmãos:____________________________________________________________________________________________________________________________________________

_________________________________________________________________________

Historia Patológica Pregressa (enfermidades e tratamentos atuais e anteriores): ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Exame Psíquico:

Aparência: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________

Comportamento: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Atitude para com o entrevistador:

( )cooperativo , ( ) resistente, ( ) indiferente

Orientação

  

Observações:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________