Identificação:

Nome:___________________________________________________________________

Idade: __________Sexo: _________________ Nacionalidade: ______________________

Estado Civil: ____________________ Data de nasc.:______________________________

Escolaridade: __________________________________________________________

Profissão:________________________________________________________________

Residência (cidade/estado): __________________________________________________

Telefones para contado: _____________________________________________________

Atendimento:

Data/hora:___________________________

Queixa Principal:
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Secundária:
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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, rotina, vícios, hobbies e trabalho)

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Histórico Familiar: (pais, irmãos, conjugue e filhos)

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História Patológica Pregressa (enfermidades e tratamentos atuais e anteriores):

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Exame Psíquico: (aparência e comportamento)

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Atitude para com o entrevistador:

( ) cooperativo , ( ) resistente, ( ) indiferente

Orientação

( ) Auto-identificatória, ( ) corporal, ( )temporal, ( ) espacial, ( ) orientado em relação a

patologia

Observações:
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Atenção

Vigilância: ______________________________________________________________

Tenacidade:______________________________________________________________

Memória
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Inteligência
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Sensopercepção:

( ) Normal, ( ) Alucinação
Pensamento

( ) acelerado, ( ) retardado, ( ) fuga, ( ) bloqueio, ( ) prolixo, ( ) repetição

- Conteúdo: ( ) obsessões, ( ) hipocondrias, ( ) fobias, ( ) delírios

Observações:
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Linguagem
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Afetividade
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Humor

( ) normal; ( ) exaltado; ( ) baixa de humor; ( ) quebra súbita da tonalidade do humor

durante a entrevista;

Consciência da doença atual

( ) sim, ( ) parcialmente, ( ) não

EVOLUÇÃO, HIPÓTESE DIAGNÓSTICA E TRATAMENTO

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