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:_______________________________________________________________
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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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