Anamnese Adulto

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Fernanda Amaral 
Psicóloga 07/24287
ANAMNESE ADULTA
Nome: ________________________________________________________________
Data do atendimento: 	____________
Queixa Principal:
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Secundária:
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Sintomas:
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Histórico da Doença Atual:
Início da patologia
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Intensidade:
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Medicamentos: _______________________________________________________________________________________
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Histórico Pessoal:
Infância:
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Rotina:
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Vícios:
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Hobbies:
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Trabalho:
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Historico Familiar:
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Pais:
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Irmãos:
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Cônjugue:
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Filhos:
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Lar:
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Historia Patológica Pregressa (enfermidades e tratamentos atuais e anteriores):
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Exame Psíquico: 
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Aparência:
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Comportamento:
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Atitude para com o entrevistador:
( )cooperativo , ( ) resistente, ( ) indiferente
Orientação
( )Auto-identificatória, ( ) corporal, ( )temporal, ( ) espacial, ( ) orientado em relação a patologia
Observações:
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Vigilância: _______________________________________________________________________________________
Tenacidade:
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Memória:
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Inteligência:
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Sensopercepção:
( ) normal, ( ) Alucinação
Pensamento:
( ) acelerado, ( )retardado, ( )fuga, ( ) bloqueio, ( ) prolixo, ( ) repetição
Conteúdo: ( ) obsessões, ( ) hipocondrias, ( ) fobias, ( ) delírios
Expansão do eu: (grandeza, ciúme, reivindicação, genealógico, místico, de missão salvadora, deificação, erótico, de ciúmes, invenção ou reforma, idéias fantásticas, excessiva saúde, capacidade física, beleza...).
Retração do eu: (prejuízo, auto-referência, perseguição, influência, possessão, humildades, experiências apocalípticas).
Negação do eu: (hipocondríaco, negação e transformação corporal, auto-acusação, culpa, ruína, niilismo, tendência ao suicídio).
Linguagem:
( )disartrias (má articulação )
( )afasias, verbigeração (repetição de palavas)
( )parafasia (emprego inapropriado de palavras com sentidos parecidos)
( ) neologismo
( )mussitação (voz murmurada em tom baixo)
( )logorréia (fluxo incessante e incoercível de palavras)
( ) para-respostas (responde a uma indagação com algo que não tem nada a ver com o que foi perguntado)
Afetividade:
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Humor:
( )normal; ( ) exaltado; ( )baixa de humor; ( )quebra súbita da tonalidade do humor durante a entrevista;
Consciência da doença atual:
( ) sim, ( )parcialmente, ( ) não
HIPÓTESE DIAGNÓSTICA
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