Anamnese Adulto

Data do atendimento: ____________________________________________________

Identificação:

Nome:___________________________________________________________________
Idade: __________Sexo: _________________ Nacionalidade: ______________________
Estado Civil: ____________________ Data de nasc.:______________________________
Grau de instrução:__________________________________________________________
Profissão: _______________________________________________________________
Residência (cidade/estado): __________________________________________________
Telefones para contado: _____________________________________________________

Atendimento:

Frequência: ___________________________ Data/hora:___________________________

Queixa Principal:
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Sintomas:
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Histórico da Doença Atual:

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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Histórico 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, ( ) 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).
Afetividade
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Humor
( )normal; ( ) exaltado; ( )baixa de humor; ( )quebra súbita da tonalidade do humor durante a
entrevista;

Consciência da doença atual

( ) sim, ( )parcialmente, ( ) não
HIPÓTESE DIAGNÓSTICA
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