Data do atendimento: ____________________________________________________

Identificao:

Nome:___________________________________________________________________
Idade: __________Sexo: _________________ Nacionalidade: ______________________
Estado Civil: ____________________ Data de nasc.:______________________________
Grau de instruo:__________________________________________________________
Profisso:________________________________________________________________
Residncia (cidade/estado): __________________________________________________
Telefones para contado: _____________________________________________________

Atendimento:

Frequencia:___________________________ Data/hora:___________________________

Queixa Principal:
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Secundria:
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Sintomas:
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Histrico da Doena Atual:

Incio da patologia:
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Frequncia:_______________________________________________________________
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Intensidade:______________________________________________________________
Tratamentos anteriores: ____________________________________________________
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Medicamentos:____________________________________________________________
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Histrico Pessoal:

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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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 Patolgica Pregressa (enfermidades e tratamentos atuais e anteriores):

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Exame Psquico:

Aparncia:
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Comportamento:
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Atitude para com o entrevistador:

( )cooperativo , ( ) resistente, ( ) indiferente

Orientao

( )Auto-identificatria, ( ) corporal, ( )temporal, ( ) espacial, ( ) orientado em relao a

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
- expanso do eu: (grandeza, cime, reivindicao, genealgico, mstico, de misso
salvadora, deificao, ertico, de cimes, inveno ou reforma, idias fantsticas,
excessiva sade, capacidade fsica, beleza...).
- retrao do eu: (prejuzo, auto-referncia, perseguio, influncia, possesso,
humildades, experincias apocalpticas).
- negao do eu: (hipocondraco, negao e transformao corporal, auto-acusao, culpa,
runa, niilismo, tendncia ao suicdio).
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Linguagem

( )disartrias (m articulao )
( )afasias, verbigerao (repetio de palavas)
( )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)

Afetividade
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Humor

( )normal; ( ) exaltado; ( )baixa de humor; ( )quebra sbita da tonalidade do humor

durante a entrevista;

Conscincia da doena atual

( ) sim, ( )parcialmente, ( ) no

HIPTESE DIAGNSTICA
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