anamnese adulto (1)

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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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Histórico da Doença Atual:
Início da patologia:
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Frequência:_____________________________________________________________
Intensidade:______________________________________________________________
Tratamentos anteriores: ____________________________________________________
Medicamentos:_____________________________________________________________
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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Conjugue:_________________________________________________________________
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Filhos:____________________________________________________________________
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Lar:______________________________________________________________________
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Hipótese Diagnóstica:
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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:_____________________________________________________________
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Memória
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Inteligência
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( ) 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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