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Anamnese adulto

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Anamnese adulto

  1. 1. Terapia Ocupacional Anamnese AdultoIdentificaçãoNome: _____________________________________________ Data da Avaliação: ___/___/____Data Nasc: _____/_____/______ Idade:_____ Sexo: ____ Naturalidade: ___________________Estado Civil: __________________RG: _______________ CPF: _________________________Escolaridade: __________________ Profissão: _______________Religião: ________________Endereço: _____________________________________________________________________Telefone: ____________________Cidade: __________________Estado: __________________Diagnóstico / Seqüela: ___________________________________________________________Medicação atual: ________________________________________________________________Médico responsável: _____________________________________________________________Encaminhamento: _______________________________________________________________Co-morbidades: _________________________________________________________________Responsável/acompanhante: ______________________________________________________Composição familiar: _________________________________________________________________________________________________________________________________________________________________________________________________________________________Queixa principal: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________História: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Antecedente familiar: ____________________________________________________________
  2. 2. Tratamentos anteriores / atuais (médicos, reabilitação, exames): ______________________________________________________________________________________________________________________________________________________________________________________Internação/cirurgias: _________________________________________________________________________________________________________________________________________________________________________________________________________________________História AtualUso de álcool, cigarro, outros: ______________________________________________________Sono: _________________________________________________________________________Atividades atuais: _____________________________________________________________________________________________________________________________________________Rotina diária: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Relacionamento familiar: ________________________________________________________________________________________________________________________________________Âmbito social (passeio, locais freqüentados, dificuldades): _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Atividade de vida diária / Atividade Instrumentais da Vida diária (posição: órteses /adaptações, cadeiras de rodas, dificuldades, outros)Transferências (cadeira de rodas): ______________________________________________________________________________________________________________________________________________________________________________________________________________Higiene (escovas dentes, cabelo, etc.): __________________________________________________________________________________________________________________________________________________________________________________________________________Continência/Uso do sanitário: __________________________________________________________________________________________________________________________________________________________________________________________________________________
  3. 3. Banho: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________Alimentação: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________Vestir-se: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________Atividades domésticas: _______________________________________________________________________________________________________________________________________________________________________________________________________________________Transporte público: ______________________________________________________________Dirigir carro: ____________________________________________________________________Outros: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Observações: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _______________________________ Terapeuta Ocupacional

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