CURSO DE GRADUAÇÃO EM FONOAUDIOLOGIA (FCMSCSP)

Levantamento da história (anamnese) – clínica adulto

Aluno: ______________________________ Supervisor:________________________

A) Identificação: Data da entrevista: / / 2024

Nome:___________________________________________________________________
 P: _____________________ Idade:_________ DN: ________________
 Endereço:_________________________________________ n° _____________
Bairro:________________________Cidade:____________Estado:________CEP:_______
Telefone:(__)________________________ e-mail________________________________
 Escolaridade:__________________________ Estado civil: ______________________
 Profissão:______________________________________________________________
 Nome do responsável ou acompanhante:_____________________________________

Heredograma:

 Encaminhado por:________________________________________________________

Resumo dos dados do prontuário (consultas / datas):

_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

B) Queixa
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

C) Histórico do problema (descritivo: sintomas, tempo, desenvolvimento e impacto):

_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
D) Hábitos e Saúde Geral:

Alimentação:______________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Sono:____________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Atividades físicas:__________________________________________________________
_________________________________________________________________________

Hidratação:_______________________________________________________________

Hábitos orais deletérios:_____________________________________________________

_________________________________________________________________________
_________________________________________________________________________

Tabagismo ( ) não ( )sim, tempo e quantidade/dia______________________________

_________________________________________________________________________

Ingesta de bebidas alcoólicas ( )não ( ) sim, tipo, frequência / semana e quantidade/dia

_________________________________________________________________________
_________________________________________________________________________

Maconha ( ) não ( ) sim __________________________________________________

Cocaína ( ) não ( )sim ___________________________________________________

Pigarro ( ) não ( ) sim ___________________________________________________

Tosse ( ) não ( ) sim ____________________________________________________

Acidentes:________________________________________________________________
_________________________________________________________________________

Cirurgias:_________________________________________________________________
_________________________________________________________________________

Medicamentos (uso contínuo/ atuais ou no último ano) :____________________________

_________________________________________________________________________
_________________________________________________________________________

Tratamentos realizados:_____________________________________________________
_________________________________________________________________________
E) Sintomas

Vias aéreas superiores e inferiores:____________________________________________

________________________________________________________________________
_________________________________________________________________________

Gástricos e/ou digestivos:____________________________________________________

_________________________________________________________________________
_________________________________________________________________________

Auditivos:_________________________________________________________________
_________________________________________________________________________

Presença de dor e/ou outro sintoma no corpo, cabeça, garganta, pescoço e ATM:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Outros sintomas:___________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

F) Trabalho (atividade profissional e adolescente dados da escola):

_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

G) Antecedentes Familiares: ________________________________________________

_________________________________________________________________________
_________________________________________________________________________

H) Impressões sobre o próprio comportamento comunicativo:____________________

_________________________________________________________________________
_________________________________________________________________________

Outras informações: _______________________________________________________

_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________