Anamnese

Data:__________________________________________________________________
Quemtrouxeacriana:____________________________________________________
Frequenciadoatendimento:_____________Data/hora:__________________________
1.Identificao
Nome:________________________________________________________________
Apelido:_______________________________________________________________
Idade:_____________Sexo:_______________________________________________
Localedatadenascimento:________________________________________________
Cidade:__________________________Telefone:______________________________
Escola:________________________________________________________________
Escolaridade:______________________Perodoescolar________________________
Nomedoprofessor:______________________________________________________
Observaes:____________________________________________________________
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2.Dadosfamiliares
Nomedopai:___________________________________________________________
Graudeinstruo:___________________Profisso_____________________________
Idade:___________Naturalidade:__________________Estadocivil:_______________
Nomedame:___________________________________________________________
Graudeinstruo:___________________Profisso_____________________________
Idade:___________Naturalidade:___________________Estadocivil:______________
Religiodospais:________________________________________________________
Observaes:____________________________________________________________
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Outrosfilhos
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3.Queixaoumotivodaconsulta
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Desdequandohoproblema?______________________________________________
Jprocurououtrosespecialistas?Quais?______________________________________
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Estfazendoalgumtipodetratamentomdico,psicolgico,psiquitricoouneurolgico?
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Porqu?_______________________________________________________________
Quemindicouaclnica?___________________________________________________
4.Antecedentespessoais
4.1.Gestao
Fezalgumatransfusoduranteagravidez?____________________________________
Levoualgumtombo?_____________________________________________________
Doenasduranteagestao________________________________________________
Condiesdesadedameduranteagravidez_________________________________
Condiesemocionais____________________________________________________
Houvealgumepisdiomarcanteduranteagravidez?___________________________
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4.2.Condiesdenascimento
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5.Desenvolvimento
5.1.Sade
Acrianasofreualgumacidenteousesubmeteuaalgumacirurgia?_______________
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Possuireaesalrgicas?_________________________________________________
Tembronquiteouasma?__________________________________________________
Apresentaproblemasdeviso?_____________________________________________
Edeaudio?___________________________________________________________
Dordecabea?__________________________________________________________
Jdesmaioualgumavez?___________Quando?________________________________
Comofoi?______________________________________________________________
Teveoutemconvulses?__________________________________________________
Halgumnafamliaqueapresentaproblemasdedesmaios,convulses,ataques?
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Observaes:___________________________________________________________
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5.2Alimentao
Acrianafoiamamentada?________Atquando?______________________________
Comosuaalimentao?__________________________________________________
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foradaasealimentar?_________________________________________________
Comesemderrubaracomida?_____________________________________________
Recebeajudanaalimentao?______________________________________________
Observaes:___________________________________________________________
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5.3Sono
Acrianadormebem?___________________________________________________
Comoseusono?(agitado,tranqilo)?______________________________________
Faladormindo?_________________________________________________________
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sonmbulo?___________________________________________________________
Rangeosdentes?________________________________________________________
Dormeemquartoseparadodospais?________________________________________
Comquemdorme?_______________________________________________________
Acrianaacordaevaiparaacamadospais?___________________________________
Observaes:___________________________________________________________
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5.4.Desenvolvimentopsicomotor
Comoeracomobeb?____________________________________________________
lentopararealizaralgumatarefa?__________________________________________
Vestesesozinho?________________Tomabanhosozinho?______________________
Calasesozinho?________________Sabedarnnoscalados?___________________
desastrado?___________________________________________________________
Praticaesportes?___________Quais?________________________________________
Riunhas?_______________________Chupaodedo?__________________________
Temoutramaniaoutic?Qual?_____________________________________________
Precisadeajudaparafazeralgumacoisa?_____________________________________
Observaes:____________________________________________________________
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6.Escolaridade
Acrianagostadeirescola?_____________________________________________
bemaceitapelosamigosouisolada?_____________________________________
Jrepetiuaseriealgumavez?___________________Porqu?____________________
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Gostadeestudar?_______Temohbitodeleitura?______________________________
Fazasliesqueosprofessorespassam?______________________________________
Ospaisestudamcomacriana?_____________________________________________
Mudoumuitasvezesdeescola?_____________________________________________
Porqu?_______________________________________________________________
Vaibememmatemtica?__________________________________________________
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Temdificuldadeemleituraeescrita?_________________________________________
irrequietanaescola?____________________________________________________
Emquecircunstncias?___________________________________________________
Quaisasprincipaisdificuldadesencontradasnaescola?__________________________
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Oqueosprofessoresachamdela?___________________________________________
Observaes:___________________________________________________________
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7.Linguagem
Descrevaacomunicaoatual:______________________________________________
Observaes:___________________________________________________________
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8.Sexualidade
Recebeualgumaeducaosexual?_______________Dequem?___________________
Comofoi?______________________________________________________________
Temcuriosidadesexual?__________________________________________________
Ospaisconversamsobresexualidadecomacriana?____________________________
Observaes:___________________________________________________________
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9.Aspectosambientais
Preferebrincarsozinhaoucomamigos?______________________________________
Preferebrincarcomcrianasmaioresoumenoresqueela?________________________
Fazamigoscomfacilidade?________________________________________________
Adaptasefacilmenteaomeio?______________________________________________
Comoorelacionamentodacrianacomospais?______________________________
Ecomosirmos?________________________________________________________
Quaisasmedidasdisciplinaresnormalmenteusadascomacriana?________________
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Quemasusa?___________________________________________________________
Quaisasreaesdacrianafrenteaessasmedidas?_____________________________
Observaes:___________________________________________________________
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10.Caractersticaspessoaiseafetivoemocionais
Comoacrianasobopontodevistaemocional?______________________________
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Dentreascaractersticasabaixo,emquaiselaseenquadramais?
Agressiva()
Passiva()
Dependente()
Irrequieta()
Medrosa()
Retrada()
Excitada()
Desligada()
Outros:________________________________________________________________
Comoreagequandocontrariada?____________________________________________
Atividadespreferidas:_____________________________________________________
Observaes:___________________________________________________________
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11.Atividadesdiriasdacriana
Descrevaarotinadacrianadesdequandoacordaataahoradedormir:____________
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