anamnese adulto pdf

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Data do atendimento: ____________________________________________________
Identificação:
Nome:___________________________________________________________________
Idade: __________Sexo: _________________ Nacionalidade: ______________________
Estado Civil: ____________________ Data de nasc.:______________________________
Grau de instrução:__________________________________________________________
Profissão:________________________________________________________________
Residência (cidade/estado): __________________________________________________
Telefones para contado: _____________________________________________________
Atendimento:
Frequencia:___________________________ Data/hora:___________________________
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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Frequência:________________________________________________________________
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Intensidade:______________________________________________________________
Tratamentos anteriores: ____________________________________________________
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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:
Pais:______________________________________________________________________
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Irmaos:____________________________________________________________________
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Conjugue:__________________________________________________________________
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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:
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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Atenção
 
 Vigilância: ______________________________________________________________
Tenacidade:______________________________________________________________
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).
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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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