Escolar Documentos
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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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Exame Psíquico:
Aparência:
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Comportamento:
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Orientação
Atenção
Vigilância: ______________________________________________________________
Tenacidade:______________________________________________________________
Memória
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Inteligência
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Sensopercepção
( ) normal, ( ) Alucinação
Pensamento
Linguagem
Afetividade
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Humor
HIPÓTESE DIAGNÓSTICA
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