Anamnese (PC)

Centro Bobath, Londres - baseado na avaliao feita por Mrs. Bobath

Data da Avaliao: ____________________

Nome: __________________________________________________________________________
Data de Nascimento: _____________Idade: ________ Naturalidade: ________________________
Nome do pai: __________________________________________________ Idade: ____________
Profisso: _______________________________________________________________________
Nome da me: __________________________________________________ Idade: ____________
Profisso: _______________________________________________________________________
Endereo: _________________________________________________________n: ____________
Bairro: _________________________________________ Cidade: _________________________
Telefone: (___) _____________________ celular: (___) __________________________________
Encaminhada por: _________________________________________________________________
Mdico: _________________________________________________________________________
Outros Profissionais envolvidos: _____________________________________________________
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Diagnstico/Classificao: __________________________________________________________
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Gravidez: sade da me, movimentos fetais
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Nascimento:
. semana de gestao: _____________________________________________________________

. peso de nascimento: ______________________________________________________________

. trabalho de parto: ( ) natural
( ) induzido
. durao do parto: ________________________________________________________________
. parto: ( ) normal
( ) frceps
( ) cesariana
.apgars: _________________________________________________________________________
. ressucitao: ____________________________________________________________________
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Perodo ps natal: qualquer complicao
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Idade que foi para casa: ____________________________________________________________
Idade quando foi feito o primeiro diagnstico: __________________________________________
Sade Geral da Criana: __________________________________________________________
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Convulso:

Anteriores

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Atuais

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Qual a freqncia

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Medicao

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Outras Medicaes:
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Constipao:
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Sono:
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AVDs:
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Alimentao:
-Primeiras:

( ) entubada
( ) mamadeira
( ) amamentada
-Atuais:
( ) pastoso
( ) slido
( ) auxiliada
( ) independente
. posio em que alimentada: _______________________________________________________
-Lquidos:
( ) mamadeira
( ) copo
( ) auxiliada
( ) independente
Hbitos:
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Pesquisas:
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Viso:
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Audio:

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Radiografia: quadril/coluna
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Outros: TC/EEG
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Gesso:
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Cirurgias:
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Terapia: idade que iniciou
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Atual:
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Terapeutas
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Local: ( ) escola
( ) em casa
( ) hospital
Freqncia:
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Outros profissionais: transporte
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- escola/berrio
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- tempo de descanso
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Equipamentos:

Cadeira

( ) para ficar em p
( ) para mobilidade

Comunicao:

( ) fala

( ) gestos

( ) uso dos olhos

Famlia/Social: principal responsvel/irmo

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Preocupaes dos pais:
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OBSERVAES
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