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Modelo de anamnese

(Adulto/idoso)
Nome:___________________________________________________________Data de Nascimento:___/___/___
Naturalidade: ________________________________ Nacionalidade: ___________________________________
Telefone Residencial: _________________________________Celular :__________________________________
Endereço: ______________________________________________________________________Nº __________
Bairro:_____________________________________________________ Cidade: __________________________
Escolaridade: ______________________________________ Peso: ______ kg Altura _______ cm
Médico solicitante: ___________________________________________________________________________

1. Queixa principal:

Por favor, explique:


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2. Histórico de doenças:

Por favor, explique:


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3. Queixas cognitivas:

Por favor, explique:


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4. Personalidade Prévia – Como é o seu jeito de ser? Continua assim ou houve alguma mudança?

Por favor, explique:


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5. Fale sobre seu passado:

Por favor, explique:


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6. Queixas cognitivas:

Por favor, explique:


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7. Alterações Comportamentais (Mudou de comportamento após ser acometido pela doença?):

Por favor, explique:


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8. Escolaridade/profissão: (Qual o nível de escolaridade e em que trabalha; como foi a trajetória


profissional?):

Por favor, explique:


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9. Vida pessoal: (Quem são as pessoas que convive, realiza atividades fora de casa? e ou participa de
algum grupo? Ex, igreja, clube, etc.):

Por favor, explique:


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10. Descreva sua vida atual

Por favor, explique:


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11. Dinâmica familiar

Com quem mora, irmãos (idade e profissões), pais (idade e profissão), filhos (idade e profissão) arranjo familiar,
familiares de referência.

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12. Hábitos e rotinas (O que gosta de fazer no tempo livre, Preferencias, alimentação e sono.

Por favor, explique:


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13. Quantas horas de sono por noite?
( ) 5 horas por noite ( ) 7 horas por noite
( ) 6 horas por noite ( ) 8 horas por noite ( ) mais de 8 horas por noite

14. Você fuma? ( ) não ( ) sim ____cigarros por dia ____charutos por dia ___cachimbos por dia.

15. Você é separado? A quanto tempo _________ Meses __________Anos

16. Alguma perda significativa? (falecimento de algum ente querido?


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17. Como conduziu o luto?


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18. Você ingere bebidas alcoólicas? ( ) não ( ) sim


Frequência:
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19. Tem ou já teve alguma das patologias que se seguem a baixo?

( ) Tonturas ( ) Convulsões
( ) Asma ( ) Problemas pulmonares
( ) Diabetes ( ) Bronquite
( ) Dor de cabeça frequente ( ) Glicose elevada
( ) Problemas nas válvulas cardíaca ( ) Fratura óssea
( ) Problemas cardíacos ( ) Cirurgias
( ) Colesterol alto

Antecedentes familiares, algum familiar próximo com alguma doença relaciona a você?
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20. Liste os medicamentos que você está tomando (nome e motivo)

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21. Exames
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22. Tratamentos
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Avaliador Responsável:_____________________________________ CBO. _______________


Data da avaliação: ______/______/______ Horário:_________

Observações Finais:
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