ANAMNESE ADULTO

Data do atendimento: ____________________________________________________________

1 IDENTIFICAO:

Nome: _________________________________________________________________________
Idade: _____________ Sexo: __________________ Nacionalidade: ________________________
Estado Civil: ______________________ Data de nascimento: _____________________________
Grau de instruo: ________________________________________________________________
Profisso: _______________________________________________________________________
Residncia (Cidade/Estado): ________________________________________________________
Telefones para contado: ___________________________________________________________

2 ATENDIMENTO:

Frequncia: ______________________________ Data/hora: ______________________________

a) Queixa Principal:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

b) Secundria:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

c) Sintomas:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

3 HISTRICO DA DOENA ATUAL:

a) Incio da patologia:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
 2

b) Frequncia: __________________________________________________________________
_______________________________________________________________________________

c) Intensidade: __________________________________________________________________
_______________________________________________________________________________

d) Tratamentos anteriores: ________________________________________________________

_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

e) Medicamentos: _______________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

4 HISTRICO PESSOAL:

a) Infncia: ______________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

b) Rotina: ______________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

c) Vcios: _______________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
 3

d) Hobbies: _____________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

e) Trabalho: ____________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

5 HISTRICO FAMILIAR:

a) Pais: ________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

b) Irmos: ______________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

c) Cnjuge: _____________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

d) Filhos: ______________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

e) Lar: _________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

f) Patolgica Pregressa (enfermidades e tratamentos atuais e anteriores): ________________

_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
 4

6 EXAME PSQUICO:

a) Aparncia: ___________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

b) Comportamento: ______________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

c) Atitude para com o entrevistador:

( ) cooperativo ( ) resistente ( ) indiferente

d) Orientao:
( ) Autoidentificatria ( ) corporal ( ) temporal ( ) espacial ( ) orientado em relao a patologia
Observaes:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

e) Ateno:
Vigilncia: ______________________________________________________________________
Tenacidade: ____________________________________________________________________

f) Memria: ____________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

g) Inteligncia: _________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

h) Sensopercepo:
( ) normal ( ) Alucinao

i) Pensamento:
( ) acelerado ( ) retardado ( ) fuga ( ) bloqueio ( ) prolixo ( ) repetio
* Contedo:
( ) obsesses ( ) hipocondrias ( ) fobias ( ) delrios
 5

* expanso do eu:
( ) grandeza ( ) cime ( ) reivindicao ( ) genealgico ( ) mstico, de misso
salvadora ( ) deificao ( ) ertico ( ) de cimes ( ) inveno ou reforma ( ) ideias
fantsticas ( ) excessiva sade ( ) capacidade fsica ( ) beleza ( ) outros: ____________
______________________________________________________________________________
* retrao do eu:
( ) prejuzo ( ) auto-referncia ( ) perseguio ( ) influncia ( ) possesso
( ) humildades ( ) experincias apocalpticas ( ) outros: _____________________________
______________________________________________________________________________
* negao do eu:
( ) hipocondraco ( ) negao e transformao corporal ( ) autoacusao ( ) culpa
( ) runa ( ) niilismo ( ) tendncia ao suicdio ( ) outros: ____________________________
_______________________________________________________________________________

j) Linguagem:
( ) disartrias (m articulao )
( ) afasias, verbigerao (repetio de palavras)
( ) parafasia (emprego inapropriado de palavras com sentidos parecidos)
( ) neologismo
( ) mussitao (voz murmurada em tom baixo)
( ) logorria (fluxo incessante e incoercvel de palavras)
( ) para-respostas (responde a uma indagao com algo que no tem nada a ver com o que foi
perguntado

k) Afetividade: __________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

l) Humor:
( ) normal ( ) exaltado ( ) baixa de humor ( ) quebra sbita da tonalidade do humor
durante a entrevista

m) Conscincia da doena atual:

( ) sim ( ) parcialmente ( ) no

7 HIPTESE DIAGNSTICA:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________