Data do

atendimento:____________________________________________________________________

Identificação:

Nome:___________________________________________________________________

Idade: __________Sexo: _________________ Nacionalidade: ______________________

Estado Civil: ____________________ Data de nasc.:______________________________

Grau de instrução:__________________________________________________________

Profissão:________________________________________________________________

Residência (cidade/estado): __________________________________________________

Telefones para contado: _____________________________________________________

Atendimento:

Frequencia:___________________________ Data/hora:___________________________

Queixa Principal:

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Secundária:

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Sintomas:

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Início da patologia:

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Frequência:____________________________________________________________

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Intensidade:______________________________________________________________

Tratamentos anteriores: ____________________________________________________

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Medicamentos:_________________________________________________________

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Histórico Pessoal:

Infância:______________________________________________________________

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Rotina________________________________________________________________

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Vícios:________________________________________________________________

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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 Patológica Pregressa (enfermidades e tratamentos atuais e anteriores):

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Exame Psíquico:

Aparência:

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Comportamento:

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Atitude para com o entrevistador:

( )cooperativo , ( ) resistente, ( ) indiferente

Orientação

( )Auto-identificatória, ( ) corporal, ( )temporal, ( ) espacial, ( ) orientado em relação a

patologia

Observações:

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Atenção

Vigilância: ______________________________________________________________

Tenacidade:______________________________________________________________
Memória  

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Inteligência

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Sensopercepção

( ) normal, ( ) Alucinação

Pensamento

 ( ) acelerado, ( )retardado, ( )fuga, ( ) bloqueio, ( ) prolixo, ( ) repetição

- Conteúdo: ( ) obsessões, ( ) hipocondrias, ( ) fobias, ( ) delírio