Anamnese

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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Secundária:
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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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Irmãos:____________________________________________________________________
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Cônjugue:__________________________________________________________________
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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: ______________________________________________________________
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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