anamnese adulto

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FICHA DE ANAMNESE
Identificação: ____________________________________________________
Datas dos atendimentos:
Nome:___________________________________________________________________
Idade: __________Sexo: _________________ Nacionalidade: ______________________
Estado Civil: ____________________ Data de nasc.:______________________________
Grau de instrução:__________________________________________________________
Profissão: ________________________________________________________________
Residência (cidade/estado): __________________________________________________
Telefones para contato: _____________________________________________________
Atendimento:
Frequência:___________________________ Data/hora:___________________________
Queixa Principal: 
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Secundária: 
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Sintomas:
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Histórico da Doença Atual:
Início da patologia: 
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Frequência:_______________________________________________________________________________________________________________________________________
Intensidade:______________________________________________________________
Tratamentos anteriores: ____________________________________________________
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Medicamentos:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Histórico Pessoal:	
Infância:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Rotina___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Vícios:__________________________________________________________________________________________________________________________________________________________________________________________________________________
Hobbies:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Trabalho:_________________________________________________________________________________________________________________________________________________________________________________________________________________
Histórico Familiar:
Pais:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Irmãos:_________________________________________________________________________________________________________________________________________________________________________________________________________________
Cônjugue:_______________________________________________________________________________________________________________________________________________________________________________________________________________
Filhos:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Lar:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
História Patológica Pregressa (enfermidades e tratamentos atuais e anteriores): _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Exame Psíquico:
Aparência: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Comportamento: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
 Atitude para com o entrevistador: 
( )cooperativo , ( ) resistente, ( ) indiferente
Orientação
   
( )Auto-identificatória, ( ) corporal, ( )temporal, ( ) espacial, ( ) orientado em relação a patologia
Observações:
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Atenção
   
 Vigilância: ______________________________________________________________
Tenacidade:______________________________________________________________
Memória  
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Inteligência
 ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Sensopercepção
  
( ) normal, ( ) Alucinação
Pensamento   
  
 ( ) acelerado, ( )retardado, ( )fuga, ( ) bloqueio, ( ) prolixo, ( ) repetição
 - Conteúdo: ( ) obsessões, ( ) hipocondrias, ( ) fobias, ( ) delírios 
 
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 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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ENCAMINHAMENTO PARA OUTROS PROFISSIONAIS:
ELABORAÇÃO DE PLANEJAMENTO DE ESTUDOS:
ADERÊNCIA AO TRATAMENTO: SIM ( ) NÃO ( )