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Data Do Atendimento: - 1 - Identificação
Data Do Atendimento: - 1 - Identificação
1 – IDENTIFICAÇÃO:
Nome: _________________________________________________________________________
Idade: _____________ Sexo: __________________ Nacionalidade: ________________________
Estado Civil: ______________________ Data de nascimento: _____________________________
Grau de instrução: ________________________________________________________________
Profissão: _______________________________________________________________________
Residência (Cidade/Estado): ________________________________________________________
Telefones para contado: ___________________________________________________________
2 – ATENDIMENTO:
a) Queixa Principal:
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b) Secundária:
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c) Sintomas:
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a) Início da patologia:
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b) Frequência: __________________________________________________________________
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c) Intensidade: __________________________________________________________________
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e) Medicamentos: _______________________________________________________________
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4 – HISTÓRICO PESSOAL:
a) Infância: ______________________________________________________________________
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b) Rotina: ______________________________________________________________________
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c) Vícios: _______________________________________________________________________
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d) Hobbies: _____________________________________________________________________
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e) Trabalho: ____________________________________________________________________
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5 – HISTÓRICO FAMILIAR:
a) Pais: ________________________________________________________________________
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b) Irmãos: ______________________________________________________________________
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c) Cônjuge: _____________________________________________________________________
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d) Filhos: ______________________________________________________________________
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e) Lar: _________________________________________________________________________
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6 – EXAME PSÍQUICO:
a) Aparência: ___________________________________________________________________
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b) Comportamento: ______________________________________________________________
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d) Orientação:
( ) Autoidentificatória ( ) corporal ( ) temporal ( ) espacial ( ) orientado em relação a patologia
Observações:
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e) Atenção:
Vigilância: ______________________________________________________________________
Tenacidade: ____________________________________________________________________
f) Memória: ____________________________________________________________________
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g) Inteligência: _________________________________________________________________
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h) Sensopercepção:
( ) normal ( ) Alucinação
i) Pensamento:
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j) Linguagem:
( ) disartrias (má articulação )
( ) afasias, verbigeração (repetição de palavras)
( ) parafasia (emprego inapropriado de palavras com sentidos parecidos)
( ) neologismo
( ) mussitação (voz murmurada em tom baixo)
( ) logorréia (fluxo incessante e incoercível de palavras)
( ) para-respostas (responde a uma indagação com algo que não tem nada a ver com o que foi
perguntado
k) Afetividade: __________________________________________________________________
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l) Humor:
( ) normal ( ) exaltado ( ) baixa de humor ( ) quebra súbita da tonalidade do humor durante
a entrevista
7 – HIPÓTESE DIAGNÓSTICA:
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