modelo de anamnese adulto

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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:_______________________________________________________________________________________________________________________________________
Intensidade:______________________________________________________________
Tratamentos anteriores: ____________________________________________________
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Medicamentos:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Histórico Pessoal:	
Infância:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Rotina___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Vícios:__________________________________________________________________________________________________________________________________________________________________________________________________________________
Hobbies:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Trabalho:_________________________________________________________________________________________________________________________________________________________________________________________________________________
Historico Familiar:
Pais:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Irmaos:_________________________________________________________________________________________________________________________________________________________________________________________________________________
Conjugue:_______________________________________________________________________________________________________________________________________________________________________________________________________________
Filhos:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Lar:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Historia 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
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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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