ANAMNESE

Nome: _____________________________________________ data da avaliação:___/___/___

Data de Nasc.: ___/___/___, idade:____, sexo_____, naturalidade:
____________________
Estado Civil: _____________________, RG:_________________, CPF: ____________________
Escolaridade: _____________________, Profissão: _______________, Religião:
____________

Endereço: ________________________________________________________________________
Telefone: ________________________, Cidade:_______________________ Estado: _________

QUEIXA

Diagnostico:______________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Queixa principal:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Medicação atual:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Médico responsável: ______________________________________________________________

Encaminhamento: ________________________________________________________________
Co-morbidade: ___________________________________________________________________
Responsável/acompanhante: _____________________________________________________
Grau de
parentesco:_______________________________________________________________

Com que reside atualmente:

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

História da queixa:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Antecedente familiar:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Tratamento anteriores: (médicos, profissionais de saúde, exames, reabilitação)
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Quanto temo durou: ______________________________________________________________

Histórico atual:
Uso de álcool ou outras drogas, quais?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Informações obre a vida funcional:
Sono:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Alimentação:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Trabalho:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Vida amorosa:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Sexualidade:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Rotina diária:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Relacionamento familiar:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Vida financeira:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Vida social:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Outras informações importantes:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
( ) Na última semana você sentiu (pode ser marcado mais de uma alternativa):
( ) Dor ou tensão muscular sem causa aparente;
( ) Dor de cabeça ou tontura sem causa aparente;
( ) Falta de ar ou cansaço sem causa aparente;
( ) Aumento no batimento cardíaco ou tremores sem causa aparente;
( ) Irritabilidade ou falta de paciência;
( ) Inquietação ou agitação;
( ) Vontade de se isolar;
( ) Comportamento agressivo (quebras coisas, gritar, xingar ou bater);
( ) Dificuldade de atenção ou concentração;
( ) Confusão mental (troca de nomes, troca de frases);
( ) Dificuldade de tomar decisões;
( ) Pensamentos repetitivos e instrutivos que evade a mente de maneira
desagradável;
( ) Falta de motivação/desânimo na hora de realizar tarefas/atividades;
( ) Emoção excessiva e persistente de tristeza, raiva, culpa, medo ou preocupação;
( ) Humor deprimido (angustia ou choro) com frequência;

Encaminhamentos/orientações:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

___________________________________________