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Anamnese

Gabinete de Psicologia do Hospital Psiquiátrico de Luanda. Baseado em Cheniaux (2015):


Psychopathology Handbook

Data do atendimento: _____/_______/_______

Identificação

Nome:_______________________________________________________________________

Idade: __________ Sexo: ________________ Nacionalidade: ______________________

Estado civil: ______________ Habilitações literárias: _________________________

Profissão e ou ocupação: _______________________________________________________

Residência: _________________________________________________________________

Telefones para contacto: _____________________________

Queixa Principal:

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Secundária:

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Sintomas:

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História da Doença Actual:

Início da patologia:

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Freqüência:
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Intensidade:
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Tratamentos anteriores (incluindo ervanários e medicina tradicional)


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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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História Familiar:

Pais:________________________________________________________________________
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Irmaos:______________________________________________________________________
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Cônjuge:_____________________________________________________________________
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Filhos:_______________________________________________________________________
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Lar:_________________________________________________________________________
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História 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:
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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, ( ) delírios

- expansão do eu: (grandeza, ciúme, reivindicação, genealógico, místico, de missão salvadora,


deificação, erótico, de ciúmes, invenção ou reforma, idéias fantásticas, excessiva saúde,
capacidade física, beleza...).

- retração do eu: (prejuízo, auto-referência, perseguição, influência, possessão, humildades,


experiências apocalípticas).

- negação do eu: (hipocondríaco, negação e transformação corporal, auto-acusação, culpa,


ruína, niilismo, tendência ao suicídio).

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Linguagem

( )disartrias (má articulação )

( )afasias, verbigeração (repetição de palavas)

( )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)

Afectividade

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Humor

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


a entrevista;

Consciência da doença actual: Insight

( ) sim, ( )parcialmente, ( ) não

HIPÓTESE DIAGNÓSTICA

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