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PREFEITURA MUNICIPAL DE COLOMBO

SECRETARIA MUNICIPAL DE SADE


CAPS_AD COLOMBO
CENTRO DE ATENO PSICOSSOCIAL
LCOOL E OUTRAS DROGAS

ANAMNESE DE ACOLHIMENTO
Nome_____________________________________________________________________________
Idade______ Data de nascimento: ____/ ____ / ____ Escolaridade:___________________________
Estado civil __________________ Filhos____________ Carto SUS___________________________
U.S de Referncia:______________________________ Profisso_____________________________
Trabalha atualmente: ( ) sim ( ) no Recebe algum benefcio (Previdencirio ou Assistencial)?
( ) sim ( ) no
Qual: ( )BPC ( ) Auxilio Doena ( ) Aposentadoria ( ) Penso por morte OBS: (Prxima Percia)
__________________________________________________________________________________
Alguma pendncia judicial ou ocorrncia policial? __________________________________________
Qual o motivo da busca pelo CAPS?_____________________________________________________
J freqentou algum CAPS? ( )sim ( ) no Qual? ______________________________________
Histrico de Uso / Abuso de SPA : 1) substncias 2) quantidade 3) tempo de uso 4) maior tempo
abstmio:__________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Histrico de internamentos / tratamentos : ( )Hospital Psiquitrico ( )Hospital - Dia ( ) CAPS ( )
Ambulatrio ( )C.T ( ) Clnicas Outros:_________________________________________________
Tempo mdio dos tratamentos:__________________________ Tipo de Alta:____________________
Apresenta Co-morbidades ? (Histrico de tratamentos anteriores)______________________________
__________________________________________________________________________________
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Necessita de tratamento / acompanhamento alm do CAPS?


__________________________________________________________________________________
____________________________________________________________________________
Hipertenso? ( ) sim ( ) no Em uso de medicao? (Qual,Quantidade, Horrios)
__________________________________________________________________________________
__________________________________________________________________________________
Faz uso de alguma medicao?(Qual, Quantidade, Horrios)
__________________________________________________________________________________
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Realizou

exames

laboratoriais

recentemente

(data

quais

os

exames

realizados)?

__________________________________________________________________________________
__________________________________________________________________________________
________________________________________________________________________
Histrico Familiar (Uso, Abuso, Dependncia). Grau de parentesco e tipo de SPA de
abuso:____________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Qual sua rotina diria?
__________________________________________________________________________________
__________________________________________________________________________________
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OBS:_____________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
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Regime de tratamento:____________________________________________________________
Data: _____ /_____ / ______ - Profissional responsvel: _________________________________