ANAMNESE ADULTO

Data do atendimento: _____/_____/_____ Identificação:

Nome:__________________________________________________________________________
Idade: __________Estado Civil: ____________________ Data de nasc.:_____________________
Grau de instrução:________________________________________________________________
Profissão:_____________________________________________________________________
Residência (cidade/estado): ______________________________________________________
Telefones para contato: _________________________________________________________
Queixa Principal:
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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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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

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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