Modelo anamnese clínica criança
Por: psijessicareis • 23/7/2019 • Ensaio • 278 Palavras (2 Páginas) • 449 Visualizações
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:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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