Anamnese Adulto

Identificação:
Nome:______________________________________________________________
Data de Nasc.:______________________ Idade:___________________________
Endereço:___________________________________________________________
Sexo:_____________________ Estado Civil:______________________________
Naturalidade:___________________Escolaridade:_________________________
Profissão:___________________________________________________________
Telefones:___________________________________________________________

Atendimento
Frequência:_______________ Data:_______________ Horário:_____________

Queixa Principal:_____________________________________________________
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Secundária:_________________________________________________________
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Principais dificuldades:________________________________________________
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Principais Objetivos:__________________________________________________
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Histórico do problema atual:
Início dos sintomas:___________________________________________________
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Frequência:_________________________________________________________
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Intensidade:_________________________________________________________
Tratamentos Anteriores:______________________________________________
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Tratamentos Atuais:__________________________________________________
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Medicamentos:_______________________________________________________
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Histórico Pessoal:
Infância e Adolescência:_______________________________________________
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Rotina Atual:________________________________________________________
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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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Cônjuge:____________________________________________________________
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Filhos:______________________________________________________________
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Lar (com quem reside):________________________________________________
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Exame Psíquico:
Aparência:__________________________________________________________
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Comportamento:_____________________________________________________
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Afetividade:_________________________________________________________
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Humor: ( )normal, ( )exaltado, ( )baixa de humor, ( )queda súbita da

tonalidade do humor durante a entrevista.

Consciência da doença atual:

( ) sim, ( )parcialmente, ( )não.

Observações:________________________________________________________
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Data:__________________________
Profissional Responsável:______________________________________________