Anamnese – Avaliação Neuropsicológica

Nome do paciente: _______________________________________________________

Idade: ________ Data Nascimento: ____/____/___ Telefone: _______________

Escolaridade: _____________________ Ocupação:____________________________

Acompanhante:__________________________________________________________

Queixa principal: ________________________________________________________

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Indicação de Avaliação: ___________________________________________________
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Informações sobre a família

Composição Familiar:

Dinâmica familiar:

Histórico de transtornos mentais na família:

Perfil de Desenvolvimento

Acontecimentos importantes ao longo da vida: ________________________________

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Histórico de Doenças importantes durante o desenvolvimento:

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Condições Atuais

Queixa Inicial: __________________________________________________________

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Início do problema:
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Evolução do quadro até a apresentação atual:

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Estratégias de enfrentamento:
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Tratamentos realizados/ Medicação:

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Doenças/Comorbidades:
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Expectativas em relação ao tratamento: ______________________________________

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Aspectos sociais/ Rede de Apoio

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Informações adicionais:
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