psi Fernanda Anamnese Adulto

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Fernanda Amaral 
Psicóloga 07/24287 
 
 
ANAMNESE ADULTA 
Nome: ________________________________________________________________ 
Data do atendimento: _ ____________ 
Frequência: ______________________ Dia/horário: ________________________________________ 
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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Tratamentos anteriores: 
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Fernanda Amaral 
Psicóloga 07/24287 
 
 
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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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Fernanda Amaral 
Psicóloga 07/24287 
 
 
Pais: 
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Irmãos: 
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Cônjugue: 
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Filhos: 
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Lar atual: 
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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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Fernanda Amaral 
Psicóloga 07/24287 
 
 
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: 
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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). 
Fernanda Amaral 
Psicóloga 07/24287 
 
 
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/OBSERVAÇÕES 
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Fernanda Amaral 
Psicóloga 07/24287