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:

Mãe:_________________________________________________________________
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Pai:__________________________________________________________________
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Irmaos:_______________________________________________________________
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Conjugue:_____________________________________________________________
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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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