Anamnese Infantil - Sarah e.mail

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<p>Sarah Cassimiro Marques</p><p>Nepneuro</p><p>Data: ____/____/____</p><p>Numero______________</p><p>Anamnese Infantil</p><p>Entrevista/Anamnese com a Mãe (Spreen & Strauss, 1998)</p><p>1 – Identificação</p><p>Nome:_____________________________________________________________________________________________</p><p>Idade: ____________________Data de Nascimento: __________________________________________________</p><p>Sexo:_______________________Escolaridade:__________________________________________________________</p><p>Escola:_____________________________________________________________________________________________</p><p>____________________________________________________________________________________________________</p><p>Pai:________________________________________________________________________________________________</p><p>Idade:_____________________Profissão:______________________________________________________________</p><p>Mãe:_______________________________________________________________________________________________</p><p>Idade:_____________________Profissão:______________________________________________________________</p><p>Telefones: _________________________________________________________________________________________</p><p>2 – Encaminhamento: _____________________________________________________________________________</p><p>3 – Queixa ou motivo da consulta</p><p>Queixa principal (o que fez procurar ajuda e avaliação neuropsicológica) ____________________________________________________________________________________________________________</p><p>________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________</p><p>Outras Queixas:___________________________________________________________________________________________</p><p>Atitude frente as queixas:</p><p>a) Mãe:____________________________________________________________________________________________________</p><p>b) Pai: ____________________________________________________________________________________________________</p><p>c) Parentes:______________________________________________________________________________________________</p><p>Medicamentos:________________________________________________________________________________________________________________________________________________________________________________________________________</p><p>Paciente sendo acompanhado por outro profissional:_______________________________________________________________________________________________</p><p>Solicitar exames (se tiver algum exame que envolva sistema nervoso central – tomografia, ressonância ou eletroencefalograma)</p><p>4 – Antecedentes Pessoais</p><p>Concepção</p><p>A criança foi desejada?________________________________________________________________________________________________</p><p>Posição na ordem das gestações:____________________________________________________________________________________________________________________________________________________________________________________________________________</p><p>Abortos:__________________________________________________________________________________________________</p><p>Gestação</p><p>Fez pré-natal, como foi a evolução? Lembra como se sentia? Doenças / Sensações / Quedas / Medicamentos / Exposição a Rx / Uso de cigarro, álcool e outras drogas.</p><p>____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________</p><p>Condições do Nascimento</p><p>( ) Em casa ( ) Maternidade</p><p>Desenvolvimento do parto</p><p>( ) Natural ( ) Fórceps ( ) Cesariana</p><p>Posição do Nascimento</p><p>( ) De cabeça ( ) Ombro ( ) Nádegas</p><p>Desenvolvimento Neuropsicomotor</p><p>Primeiras reações:</p><p>( ) Chorou ( ) Vermelho ( ) Roxo</p><p>( )Anóxia ( ) Icterícia ( ) Precisou de oxigênio</p><p>( ) Incubadora</p><p>Alta hospitalar:__________________________________________________________________________________________</p><p>Como foi o clima familiar na recepção da criança?</p><p>________________________________________________________________________________________________________________________________________________________________________________________________________________________</p><p>QUANTOS ANOS?????</p><p>Sorriu?___________________ Equilíbrio de pescoço?_________________________________________________________</p><p>Engatinhou?___________________Sentou?__________________________________________________________________</p><p>Andou?______________________Falou as primeiras palavras?_____________________________________________</p><p>Falou corretamente?______________Trocou letras?________________________________________________________</p><p>Gaguejou?_________________Dentição ( 1 e 2)______________________________________________________________</p><p>Controle dos esfíncteres: Anal diurno_____________________________________________</p><p>Vesical diurno_____________ noturno_____________________</p><p>Estava sob os cuidados de quem? ________________________________________________________________________</p><p>Manipulações</p><p>Usou chupeta ________________Chupou o dedo ___________________________________________________________</p><p>Roí unhas _____________________ Puxa a orelha __________________________________________________________</p><p>Arranca os cabelos ____________ Morde os lábios ___________________________________</p><p>Tíques ________________________________________________________________________</p><p>Atitude tomada diante desses hábitos __________________________________________</p><p>Sono</p><p>Dorme bem________________ Pula quando dorme___________________ Horário: ____________________________</p><p>Baba a noite___________________ Sudorese_________________________________________________________________</p><p>Acorda várias vezes durante a noite e torna a dormir_________________________________________________</p><p>Fala dormindo_______________Grita_______________________________________________________________________</p><p>Range os dentes________________ Sonâmbulo______________________________________________________________</p><p>Pesadelos_________________________________________________________________________________________________</p><p>Alimentação</p><p>Foi amamentado no peito, atitude no desmame, como são os hábitos alimentares.</p><p>________________________________________________________________________________________________________________________________________________________________________________________________________________________</p><p>________________________________________________________________________________________________________________________________________________________________________________________________________________________</p><p>Escolaridade</p><p>Vai bem na escola?_______________________________________________________________________________________</p><p>Gosta de estudar_________________________________________________________________________________________</p><p>Histórico escolar____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________</p><p>________________________________________________________________________________________________________________________________________________________________________________________________________________________</p><p>Gosta da escola___________________________________________________________________________________________</p><p>Queixas de comportamento_______________________________________________________________________________</p><p>________________________________________________________________________________________________________________________________________________________________________________________________________________________</p><p>Dificuldade em escrita___________________________________________________________________________________</p><p>Dificuldades em cálculo __________________________________________________________________________________</p><p>Dificuldades em leitura _________________________________________________________________________________</p><p>Outras dificuldades ______________________________________________________________________________________</p><p>Preferência lateral ______________________________________________________________________________________</p><p>Vida social</p><p>Prefere brincar sozinho ou com os amigos, afetividade, família, amizades, parentes, círculo de convivências.</p><p>____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________</p><p>____________________________________________________________________________________________________________</p><p>Sexualidade</p><p>Curiosidades sexual, atitudes dos pais, masturbação, educação sexual.</p><p>____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________</p><p>Doenças</p><p>Febre, convulsões, operações, anestesia, alergias.</p><p>____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________</p><p>5 - Antecedentes familiares (Alguém na família com algum diagnóstico de Transtorno Mental, por exemplo, Depressão, Esquizofrenia, Dependente Químico - fumante, alcoolista)</p><p>____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________6 - Habilidades não-acadêmicas</p><p>Esportes, bicicleta, joga bola, vídeo-game, leitura, tarefas</p><p>domésticas, interesse por mecânica, aparelhos eletrônicos, instrumentos musicais.</p><p>____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________</p><p>7 - Ambiente familiar</p><p>____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________</p><p>Observações</p><p>____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________</p>