ESPECIALIZAÇÃO EM NEUROPSICOLOGIA

Instituto Suassuna e Incantato

Coordenação: Profa. Ms. Sarah Cassimiro Marques
Especialização em Neuropsicologia
Profa. Dra. Andréa Batista Magalhães

(MODELO PARA ESTUDO / NÃO AUTORIZADA PARA APLICAÇÃO)

Data do atendimento: ____________________________________________________________

1 – IDENTIFICAÇÃO:

Nome: _________________________________________________________________________
Idade: _____________ Sexo: __________________ Nacionalidade: ________________________
Estado Civil: ______________________ Data de nascimento: _____________________________
Grau de instrução: ________________________________________________________________
Profissão: _______________________________________________________________________
Residência (Cidade/Estado): ________________________________________________________
Telefones para contado: ___________________________________________________________

2 – ATENDIMENTO:

Frequência: ______________________________ Data/hora: ______________________________

a) Queixa Principal:
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b) Secundária:
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c) Sintomas:
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3 – HISTÓRICO DA DOENÇA ATUAL:

a) Início da patologia:
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b) Frequência: __________________________________________________________________
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c) Intensidade: __________________________________________________________________
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d) Tratamentos anteriores: ________________________________________________________

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e) Medicamentos: _______________________________________________________________
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4 – HISTÓRICO PESSOAL:

a) Infância: ______________________________________________________________________
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b) Rotina: ______________________________________________________________________
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c) Vícios: _______________________________________________________________________
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d) Hobbies: _____________________________________________________________________
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e) Trabalho: ____________________________________________________________________
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5 – HISTÓRICO FAMILIAR:

a) Pais: ________________________________________________________________________
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b) Irmãos: ______________________________________________________________________
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c) Cônjuge: _____________________________________________________________________
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d) Filhos: ______________________________________________________________________
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e) Lar: _________________________________________________________________________
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f) Patológica Pregressa (enfermidades 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:
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e) Atenção:
Vigilância: ______________________________________________________________________
Tenacidade: ____________________________________________________________________

f) Memória: ____________________________________________________________________
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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: __________________________________________________________________
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l) Humor:
( ) normal ( ) exaltado ( ) baixa de humor ( ) quebra súbita da tonalidade do humor
durante a entrevista

m) Consciência da doença atual:

( ) sim ( ) parcialmente ( ) não

7 – HIPÓTESE DIAGNÓSTICA:
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