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Datadoatendimento:____________________________________________________

Identificao:
Nome:___________________________________________________________________
Idade:__________Sexo:_________________Nacionalidade:______________________
EstadoCivil:____________________Datadenasc.:______________________________
Graudeinstruo:__________________________________________________________
Profisso:________________________________________________________________
Residncia(cidade/estado):__________________________________________________
Telefonesparacontado:_____________________________________________________
Atendimento:
Frequencia:___________________________Data/hora:___________________________
QueixaPrincipal:
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Secundria:
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Sintomas:
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HistricodaDoenaAtual:
Inciodapatologia:
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Frequncia:____________________________________________________________
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Intensidade:______________________________________________________________
Tratamentosanteriores:____________________________________________________
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Medicamentos:_________________________________________________________
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HistricoPessoal:
Infncia:______________________________________________________________
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Rotina________________________________________________________________
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Vcios:________________________________________________________________
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Hobbies:______________________________________________________________
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Trabalho:_____________________________________________________________
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HistoricoFamiliar:

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 Patolgica Pregressa (enfermidades e tratamentos atuais e anteriores):
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ExamePsquico:
Aparncia:
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Comportamento:
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Atitudeparacomoentrevistador:
()cooperativo,()resistente,()indiferente
Orientao

()Autoidentificatria,()corporal,()temporal,()espacial,()orientadoemrelaoa
patologia
Observaes:
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Ateno

Vigilncia:______________________________________________________________
Tenacidade:______________________________________________________________
Memria
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Inteligncia
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Sensopercepo

()normal,()Alucinao
Pensamento

()acelerado,()retardado,()fuga,()bloqueio,()prolixo,()repetio
Contedo:()obsesses,()hipocondrias,()fobias,()delrios

expansodoeu:(grandeza,cime,reivindicao,genealgico,mstico,demisso
salvadora,deificao,ertico,decimes,invenooureforma,idiasfantsticas,
excessivasade,capacidadefsica,beleza...).
retraodoeu:(prejuzo,autoreferncia,perseguio,influncia,possesso,
humildades,experinciasapocalpticas).
negaodoeu:(hipocondraco,negaoetransformaocorporal,autoacusao,culpa,
runa,niilismo,tendnciaaosuicdio).
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Linguagem
()disartrias(marticulao)
()afasias,verbigerao(repetiodepalavas)
()parafasia(empregoinapropriadodepalavrascomsentidosparecidos)
()neologismo
()mussitao(vozmurmuradaemtombaixo)
()logorria(fluxoincessanteeincoercveldepalavras)
()pararespostas(respondeaumaindagaocomalgoquenotemnadaavercomo
quefoiperguntado)
Afetividade
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Humor
()normal()exaltado()baixadehumor()quebrasbitadatonalidadedohumor
duranteaentrevista
Conscinciadadoenaatual
()sim,()parcialmente,()no
HIPTESEDIAGNSTICA
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