( Logomarca )

ANAMNESE ADULTO

Data do atendimento: ___/____/_____

1 – IDENTIFICAÇÃO:

Nome: _________________________________________________________________

Idade: __________ Sexo: ______________________ Nacionalidade: ______________

Estado Civil: ____________________ Data de nascimento: ____/____/_____

Grau de instrução: _______________________________________________________

Profissão: ______________________________________________________________

Residência (Cidade/Estado): _______________________________________________

Telefones para contato: ________________________/__________________________

2 – ATENDIMENTO:

Frequência:_________________________
Data/hora: _________________________

Queixa Principal:

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 Secundária:
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Sintomas:
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3 – HISTÓRICO DA DOENÇA ATUAL:

Início da patologia:
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Frequência:
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Intensidade:
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Tratamentos anteriores:
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Medicamentos:
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4 - 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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5 - HISTÓRICO FAMILIAR:
Pais:
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Irmãos:
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Cônjuge:
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Filhos:
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Lar:
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Patológica Pregressa (enfermidades e tratamentos atuais e anteriores):

6 - EXAME PSÍQUICO:

Aparência:
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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:

Atenção:
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Vigilância:
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Tenacidade:
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Memória:
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Inteligência:
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Senso percepção:
( ) normal
( ) alucinação

Pensamento:
( ) acelerado
( ) retardado
( ) fuga
( ) bloqueio
( ) prolixo
( ) repetição

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

Expansão do eu:
( ) grandeza
( ) ciúme
( ) reivindicação
( ) genealógico
( ) místico, de missão salvadora
( ) deificação
( ) erótico
( ) de ciúmes
( ) invenção ou reforma
( ) ideias fantásticas
( ) excessiva saúde
( ) capacidade física
( ) beleza
outros:
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Retração do eu:
( ) prejuízo
( ) auto-referência
( ) perseguição
( ) influência
( ) possessão
( ) humildes
( ) experiências apocalípticas
outros: _____________________________________________________________________
Negação do eu:
( ) hipocondríaco
( ) negação e transformação corporal
( ) auto acusação
( ) culpa
( ) ruína
( ) niilismo
( ) tendência ao suicídio
outros:_____________________________________________________________________

Linguagem:

( ) disartrias (má articulação )

( ) afasias, verbigeração (repetição de palavras)
( ) parafasia
( ) neologismo
( ) mussitação (voz murmurada em tom baixo)
( ) logorréia (fluxo incessante e incoercível de palavras)
( ) para-respostas (responde a uma indagação com algo que não tem nada a ver com o que foi
perguntado)

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

7 - HIPÓTESE DIAGNÓSTICA:
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( Local / Data )

Nome do Profissional
CRP __/_____