1 IDENTIFICAÇÃO:

Nome:____________________________________________________________________________
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Idade: _____________ Sexo: __________________ CPF:
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Estado Civil: ______________________________ Data de nascimento:_______ de____________ de
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Grau de
instrução:__________________________________________________________________________
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Profissão: ______________________|______________________ Religião-
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Residência:
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Telefones: ( ) 9 ________________________ ( ) ________________________
Outro Contato ( ) 9____________________ Nome _____________________ Vínculo
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Email:
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2 ATENDIMENTO:

Frequência:__________________________ ( ) semana ( ) mês | Horário: ___________-

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Modo de atendimento: ( ) presencial ( ) online ( ) home care
Local
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a) Queixa Principal (quando, onde e como começou):

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b) Secundária (quando, onde e como começou):
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c) Sintomas (reações fisicas, emocionais):

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3 HISTÓRICO DA DOENÇA ATUAL:

a) Início da patologia:
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b) Frequência (o quanto isso se repete, algum periodo regular?):

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c) Intensidade (quão forte ou fraco lhe parece, o quanto se apresenta):

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d) Tratamentos anteriores:
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e) Medicamentos:
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5 HISTÓRICO PESSOAL:

a) Infância (o que recorda da infância, como vivia, com quem, histórias marcantes, dificuldades):
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b) Rotina (como funciona seu dia a dia; final de semana):

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c) Vícios (passados ou presentes):

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d) Relações sociais (Amigos, hobbies e demais atividades):

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e) Trabalho (inicio da vida professional. Gosta do que faz? Desejo de mudança):

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5 HISTÓRICO FAMILIAR:

a) Relacionamento com os pais (como se relacionam, saude, ocupação):

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b) Irmãos (idade, sexo, como se relacionam):

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c) Cônjuge ou relacionamento atual (como se relacionam, como iniciou o relacionamento):

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d) Filhos (quantidade, sexo, idade, como se relacionam)

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e) Lar (o que sua casa representa; possui conflitos?):
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f) Patológica Pregressa (doenças ou acidentes, operações e tratamentos atuais e anteriores):

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6 EXAME PSÍQUICO:

a) Aparência: ___________________________________

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b) Comportamento:
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c) Atitude para com o entrevistador:

( ) cooperativo ( ) resistente ( ) indiferente

d) Orientação:
( )autoidentificatória ( )corporal ( )temporal ( )espacial ( )orientado em relação a patologia
Observações:

e) Atenção
Vigilância:
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Tenacidade:
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f) Memória g) Inteligência
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h) Sensopercepção:
( ) Normal ( ) Alucinação

i) 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 ( )ideias fantásticas ( )excessiva saúde ( )capacidade
física ( ) beleza
( ) outros:
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*Retração do eu:
( ) prejuízo ( )auto-referência ( )perseguição ( ) influência ( ) possessão ( ) humildades
( ) experiências apocalípticas
( ) outros:

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*Negação do eu:
( ) hipocondríaco( )negação e transformação corporal ( )autoacusação( ) culpa ( ) ruína ( ) niilismo ( )
tendência ao suicídio
( ) outros:
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j) Linguagem:
( ) disartrias (má articulação )
( ) afasias, verbigeração(repetição de
palavras)
( ) 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

k) Afetividade (estados de euforia, tristeza, irritabilidade, angústia, ambivalência e labilidade afetivas,

incontinência emocional )
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l) Humor:
( ) normal ( ) baixa de humor
( ) exaltado ( ) quebra súbita da tonalidade do humor
durante a entrevista
m) Consciência da doença atual:
( ) sim ( )parcialmente ( ) não

7 HIPÓTESE DIAGNÓSTICA:

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CID _____ _____________

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Damaris Ferreira Hipólito

CRP 05/61088