Keven Wiliam S.

Rodrigues
Psicólogo CRP 09/10808
Data: ____/____/____
Numero______________
Anamnese Infantil
Entrevista/Anamnese com a Mãe (Spreen & Strauss, 1998)

1 – Identificação

Nome:_____________________________________________________________________________________________

Idade: ____________________Data de Nascimento:__________________________________________________

Sexo:_______________________Escolaridade:__________________________________________________________

Escola:_____________________________________________________________________________________________

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Pai:________________________________________________________________________________________________

Idade:_____________________Profissão:______________________________________________________________

Mãe:_______________________________________________________________________________________________

Idade:_____________________Profissão:______________________________________________________________

Telefones: _________________________________________________________________________________________

2 – Encaminhamento:_____________________________________________________________________________

3 – Queixa ou motivo da consulta

Queixa principal:__________________________________________________________________________________

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Outras Queixas:___________________________________________________________________________________________

Atitude frente as queixas:

a) Mãe:____________________________________________________________________________________________________

b) Pai: ____________________________________________________________________________________________________

c) Parentes:______________________________________________________________________________________________

Medicamentos:____________________________________________________________________________________________

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Paciente sendo acompanhado por outro

profissional:_______________________________________________________________________________________________

Solicitar exames

4 – Antecedentes Pessoais

Concepção

A criança foi

desejada?________________________________________________________________________________________________

Posição na ordem das

gestações:_________________________________________________________________________________________________

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Abortos:__________________________________________________________________________________________________

Gestação

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.

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Condições do Nascimento

( ) Em casa ( ) Maternidade
Desenvolvimento do parto
( ) Natural ( ) Fórceps ( ) Cesariana
Posição do Nascimento
( ) De cabeça ( ) Ombro ( ) Nádegas
Desenvolvimento Neuropsicomotor
Primeiras reações:
( ) Chorou ( ) Vermelho ( ) Roxo
( )Anóxia ( ) Icterícia ( ) Precisou de oxigênio
( ) Incubadora
Alta hospitalar:__________________________________________________________________________________________
Como foi o clima familiar na recepção da criança?
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Sorriu?___________________Equilíbrio de pescoço?_________________________________________________________

Engatinhou?___________________Sentou?__________________________________________________________________

Andou?______________________Falou as primeiras palavras?_____________________________________________

Falou corretamente?______________Trocou letras?________________________________________________________

Gaguejou?_________________Dentição ( 1 e 2)______________________________________________________________

Controle dos esfíncteres: Anal diurno_____________________________________________

Vesical diurno_____________noturno_____________________

Estava sob os cuidados de quem? ________________________________________________________________________

Manipulações

Usou chupeta ________________Chupou o dedo ___________________________________________________________

Roí unhas _____________________ Puxa a orelha __________________________________________________________

Arranca os cabelos ____________ Morde os lábios ___________________________________

Tíques ________________________________________________________________________

Atitude tomada diante desses hábitos __________________________________________

Sono

Dorme bem________________ Pula quando dorme___________________ Horário: ____________________________

Baba a noite___________________ Sudorese_________________________________________________________________

Acorda várias vezes durante a noite e torna a dormir_________________________________________________

Fala dormindo_______________Grita_______________________________________________________________________

Range os dentes________________ Sonâmbulo______________________________________________________________

Pesadelos_________________________________________________________________________________________________

Alimentação

Foi amamentado no peito, atitude no desmame, como são os hábitos alimentares.

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Escolaridade

Vai bem na escola?_______________________________________________________________________________________

Gosta de estudar_________________________________________________________________________________________

Histórico

escolar____________________________________________________________________________________________________

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Gosta da escola___________________________________________________________________________________________

Queixas de comportamento_______________________________________________________________________________

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Dificuldade em escrita___________________________________________________________________________________

Dificuldades em cálculo __________________________________________________________________________________

Dificuldades em leitura _________________________________________________________________________________

Outras dificuldades ______________________________________________________________________________________

Preferência lateral ______________________________________________________________________________________

Vida social

Prefere brincar sozinho ou com os amigos, afetividade, família, amizades, parentes, círculo de

convivências.

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Sexualidade

Curiosidades sexual, atitudes dos pais, masturbação, educação sexual.

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Doenças

Febre, convulsões, operações, anestesia, alergias.

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5 - Antecedentes familiares

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6 - Habilidades não-acadêmicas

Esportes, bicicleta, joga bola, vídeo-game, leitura, tarefas domésticas, interesse por mecânica,

aparelhos eletrônicos, instrumentos musicais.

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7 - Ambiente familiar

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Observações

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