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Identificação
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Residência: _________________________________________________________________
Queixa Principal:
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Secundária:
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Sintomas:
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Início da patologia:
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Freqüência:
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Intensidade:
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Medicamentos:
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Histórico Pessoal:
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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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Exame Psíquico:
Aparência:
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Comportamento:
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Orientação
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
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Linguagem
( ) neologismo
( )mussitação (voz murmurada em tom baixo)
( ) 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
HIPÓTESE DIAGNÓSTICA
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