ANAMNESE

Atendimento Educacional EspecializadoANAMNESE

DATA: ____/____/_______

I - IDENTIFICAO Nome da criana: ________________________________________________________________________

Data de Nasc: _____/_____/_________ Idade: ______________________

Nome da Me:___________________________________________________________________________

Nome do Pai: ___________________________________________________________________________

Responsvel pela criana:__________________________________________________________________

Telefones: ______________________________________________________________________________Quem reside na casa? ( composio familiar)NomeParentescoIdade

II HISTRICO DA CRIANAA criana est matriculada em alguma unidade bsica de sade? Sim ( ) No ( )

Qual?_________________________________________________________________________________

Possui convnio mdico? Sim ( ) No ( )Qual? _________________________________________________________________________________

Freqenta alguma escola ou freqentou? Sim ( ) No ( )

Qual? _________________________________________________________________________________

III ANTECEDENTES GESTACIONAIS E NEONATAISHavia doena preexistente da me antes da gravidez? Sim ( ) No ( )Qual?_________________________________________________________________________________

Fez pr-natal? Sim( ) No( )

Durante a gravidez adquiriu alguma doena? Sim ( ) No ( )

Qual?_________________________________________________________________________________

Fez tratamento? Sim( ) No( )

Usou medicamento (s)? Sim( ) No( )

Qual(is)? _______________________________________________________________________________Local onde a criana nasceu:_______________________________________________________________PARTO

( ) normal

( ) cesariana

( ) frceps

NASCEU A

( ) termo

( ) Pr-termo

( ) Ps-termo

AO NASCER

( ) chorou logo

( ) demorou pra chorar

Apgar ______ / _______

Peso:_______________ Altura:________________Fototerapia? Sim( ) No ( )Houve problemas na hora do nascimento? Sim ( ) No ( )

Qual(is)________________________________________________________________________________

Quando a me recebeu alta da maternidade, o RN tambm recebeu? Sim ( ) No ( )

Porque no? ____________________________________________________________________________

O RN ao nascer ficou em:

( ) berrio

( ) alojamento conjunto

( ) enfermaria comum

( ) UTI peditrica

( ) Nasceu em casa

Realizou o teste do pezinho ? ____________________________________________________________

A criana possui alguma doena gentica, seqela de doena, trauma ou outra doena especfica?

( ) Sim ( ) No ( ) Em investigao

Qual (is)? ______________________________________________________________________________

Faz acompanhamento? ( ) Sim ( ) No

Onde? _________________________________________________________________________________A me amamentou? ( ) Sim ( ) No

Durante quanto tempo? ___________________________________________________________________

IV DESENVOLVIMENTOSorriu aos ___________meses

Sustentou a cabea com ___________________________________________________________________Sentou com ____________________________________________________________________________Engatinhou com ________________________________________________________________________Andou com ____________________________________________________________________________Falou com _____________________________________________________________________________Dentio aos ___________________________________________________________________________Controla esfncteres? ( ) Sim ( ) No

Usa chupeta? ( ) Sim ( ) No

Enurese? ( ) Sim ( ) No

Encoprese? ( ) Sim ( ) No

Usa mamadeira ( ) Sim ( ) No

Alimenta-se sozinho ( ) Sim ( ) NoToma banho sozinho ( ) Sim ( ) No

Veste-se sozinho ( ) Sim ( ) No

Sono: ( ) Agitado ( ) Tranqilo ( ) Fala dormindo ( ) Sonambulismo V IMUNIZAO ( vacinao )Completa ( ) Incompleta ( )

Vacinas especiais? ( ) Sim ( ) No

Qual (is)? ______________________________________________________________________________VI DISTRBIOSViso ( ) _______________________________________________________________________

Audio ( ) __________________________________________________________________________

Fala ( linguagem) ( ) _________________________________________________________________

Motor ( ) ______________________________________________________________________________

Neurolgico ( ) _________________________________________________________________________

Psicolgico ( ) _________________________________________________________________________

Endocrinolgico ( ) __________________________________________________________________

Sindrmico ( ) ________________________________________________________________________

Aprendizagem ( ) ____________________________________________________________________

Outros? _______________________________________________________________________

Quais? _______________________________________________________________________Faz uso de medicamento(s) atualmente?

Qual(is)? _______________________________________________________________________

VII DOENAS PRPRIAS DA INFNCIA( ) catapora ( ) hepatite ( ) rubola ( ) caxumba ( ) meningite ( ) encefalite

( ) pneumonia ( ) rinite ( ) outras

Quais ? ______________________________________________VIII HISTRICO PREGRESSO DA CRIANA

Internaes? ( ) Sim ( ) No Quantas? _____________________________________________

Porque?________________________________________________________________________________ Cirurgias? ( ) Sim ( ) No Quais? _______________________________________________

______________________________________________________________________________________

Fraturas? ( ) Sim ( ) No Onde e motivo? ________________________________________

Possui alergia a algum tipo de medicamento(s) ou substncia(s) ( ) Sim ( ) NoQual (is) _______________________________________________________________________________

Usa culos? ( ) Sim ( ) No _________________________________________________________Usa prtese auditiva? ( ) Sim ( ) No ___________________________________________________

IX HISTRICO ATUAL DA CRIANAFaz acompanhamento mdico ou no mdico:

Neurolgico( ) _____________________________________________________________________

Oftalmolgico( ) _____________________________________________________________________

Ortopdico ( ) _____________________________________________________________________

Psiquitrico( ) _____________________________________________________________________

Otorrinolaringolgico( ) ________________________________________________________________

Psicolgico ( ) _____________________________________________________________________

Odontolgico( ) _____________________________________________________________________

Fonoaudiolgico( ) _____________________________________________________________________

Fisioterpico( ) _____________________________________________________________________

Pedaggico ( ) _____________________________________________________________________

Outros: _____________________________________________________________________ X OBSERVAES E CONDUTAS_____________________________________________________________________________________

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________________________________ ____________________________________ Professor Sala multifuncional Entrevistador