Anamnese-Adulto docx

Prévia do material em texto

( Logomarca )
ANAMNESE ADULTO
Data do atendimento: ___/____/_____
1 – IDENTIFICAÇÃO:
Nome: _________________________________________________________________
Idade: Sexo: ______________________ Nacionalidade: ______________
Estado Civil: ____________________ Data de nascimento: ____/____/_____
Grau de instrução: _______________________________________________________
Profissão: ______________________________________________________________
Residência (Cidade/Estado): _______________________________________________
Telefones para contato: ________________________/__________________________
2 – ATENDIMENTO:
Frequência:_________________________
Data/hora: _________________________
Queixa Principal:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Secundária:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Sintomas:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
3 – HISTÓRICO DA DOENÇA ATUAL:
Início da patologia:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Frequência:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Intensidade:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Tratamentos anteriores:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Medicamentos:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
4 - HISTÓRICO PESSOAL:
Infância:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Rotina:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Vícios:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Hobbies:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Trabalho:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
5 - HISTÓRICO FAMILIAR:
Pais:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
______________________________________________________________________________________________________________________________________________
Irmãos:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Cônjuge:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Filhos:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Lar:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Patológica Pregressa (enfermidades e tratamentos atuais e anteriores):
4 – EXAME PSÍQUICO:
Aparência:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Comportamento:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Atitude para com o entrevistador:
Cooperativo
Resistente
Indiferente
Orientação:
Auto Identificatória
Corporal
Temporal
Espacial
Orientado em relação a patologia
Observações:
Atenção:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Vigilância:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Tenacidade:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Memória:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Inteligência:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Senso percepção:
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
ideias fantásticas
excessiva saúde
capacidade física
beleza
outros: ___________________________________________
Retração do eu:
prejuízo
auto-referência
perseguição
influência
possessão
humildes
experiências apocalípticas
outros: ___________________________________________
Negação do eu:
hipocondríaco
negação e transformação corporal
auto acusação
culpa
ruína
niilismo
tendência ao suicídio
outros:________________________________________________
Linguagem:
disartrias (má articulação )
afasias, verbigeração (repetição de palavras)
parafasia
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:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Humor:
normal
exaltado
baixa de humor
quebra súbita da tonalidade do humor durante a entrevista
Consciência da doença atual:
sim
parcialmente
não
5 – HIPÓTESE DIAGNÓSTICA:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
______________________________________________________________________________________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________