entrevista inicial- anamnese

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<p>Identificação:</p><p>Nome:_______________________________________________________________</p><p>Idade:______ Sexo: ___________ Nacionalidade: _________________</p><p>Estado Civil:______________ Data de nasc.:______________________</p><p>Grau de instrução:___________________________________________</p><p>Profissão:_____________________________________</p><p>Residência(cidade/estado):_______________________________________________</p><p>Telefones para contado: ____________________________________________</p><p>Atendimento:</p><p>Frequência:___________________________ Data/hora:___________________________</p><p>Queixa Principal:</p><p>_____________________________________________________________________</p><p>_____________________________________________________________________</p><p>__________________________________________________________________________________________________________________________________________</p><p>_____________________________________________________________________</p><p>Secundária:</p><p>____________________________________________________________________</p><p>_____________________________________________________________________</p><p>_____________________________________________________________________</p><p>_____________________________________________________________________</p><p>__________________________________________________________________________________________________________________________________________</p><p>Sintomas:</p><p>_____________________________________________________________________</p><p>_____________________________________________________________________</p><p>_____________________________________________________________________</p><p>__________________________________________________________________________________________________________________________________________</p><p>_________________________________________________________________________________________________________________________________________</p><p>____________________________________________________________________</p><p>____________________________________________________________________</p><p>____________________________________________________________________</p><p>____________________________________________________________________</p><p>Histórico da Doença Atual:</p><p>Início da patologia:</p><p>____________________________________________________________________</p><p>_____________________________________________________________________</p><p>___________________________________________________________________________________________________________________________________________</p><p>Frequência:____________________________________________________________</p><p>_____________________________________________________________________</p><p>Intensidade:____________________________________________________________</p><p>Tratamentos anteriores:</p><p>_____________________________________________________________________</p><p>_____________________________________________________________________</p><p>_____________________________________________________________________ Medicamentos:_________________________________________________________</p><p>_____________________________________________________________________</p><p>_____________________________________________________________________</p><p>_____________________________________________________________________</p><p>Histórico Pessoal:</p><p>Infância:_______________________________________________________________</p><p>_____________________________________________________________________</p><p>__________________________________________________________________________________________________________________________________________</p><p>_____________________________________________________________________</p><p>_____________________________________________________________________</p><p>____________________________________________________________________</p><p>_____________________________________________________________________</p><p>Rotina________________________________________________________________</p><p>__________________________________________________________________________________________________________________________________________</p><p>_____________________________________________________________________</p><p>_____________________________________________________________________</p><p>____________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________________</p><p>Vícios:________________________________________________________________</p><p>_____________________________________________________________________</p><p>_____________________________________________________________________</p><p>Hobbies:______________________________________________________________</p><p>__________________________________________________________________________________________________________________________________________</p><p>_____________________________________________________________________</p><p>Trabalho:______________________________________________________________</p><p>_____________________________________________________________________</p><p>_____________________________________________________________________</p><p>Histórico Familiar:</p><p>Mãe:_________________________________________________________________</p><p>_____________________________________________________________________</p><p>_____________________________________________________________________</p><p>_____________________________________________________________________</p><p>Pai:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________</p><p>Irmaos:_______________________________________________________________</p><p>_____________________________________________________________________</p><p>_____________________________________________________________________</p><p>Conjugue:_____________________________________________________________</p><p>_____________________________________________________________________</p><p>____________________________________________________________________</p><p>Filhos:________________________________________________________________</p><p>_____________________________________________________________________</p><p>_____________________________________________________________________</p><p>_____________________________________________________________________</p><p>Lar:__________________________________________________________________</p><p>_____________________________________________________________________</p><p>____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________</p><p>_____________________________________________________________________</p><p>História Patológica Pregressa (enfermidades e tratamentos atuais e anteriores):</p><p>_____________________________________________________________________</p><p>__________________________________________________________________________________________________________________________________________</p><p>_____________________________________________________________________</p><p>_____________________________________________________________________</p><p>_____________________________________________________________________</p><p>_____________________________________________________________________ _____________________________________________________________________</p><p>__________________________________________________________________________________________________________________________________________ ____________________________________________________________________</p><p>Exame Psíquico:</p><p>Aparência:</p><p>_____________________________________________________________________</p><p>____________________________________________________________________</p><p>_______________________________________________________________________________________________________________________________________________________________________________________________________________</p><p>Comportamento:</p><p>_____________________________________________________________________</p><p>_____________________________________________________________________</p><p>_____________________________________________________________________</p><p>_____________________________________________________________________</p><p>_____________________________________________________________________</p><p>_____________________________________________________________________</p><p>Atitude para com o entrevistador:</p><p>( )cooperativo , ( ) resistente, ( ) indiferente</p><p>Orientação</p><p>( )Auto-identificatória, ( ) corporal, ( )temporal, ( ) espacial, ( ) orientado em relação a patologia</p><p>Observações: _____________________________________________________________________</p><p>_____________________________________________________________________</p><p>_______________________________________________________________________________________________________________________________________________________________________________________________________________</p><p>_____________________________________________________________________</p><p>Atenção:____________________________________________________________</p><p>Vigilância:_____________________________________________________________</p><p>Tenacidade:___________________________________________________________</p><p>Memória</p><p>_____________________________________________________________________</p><p>____________________________________________________________________</p><p>_______________________________________________________________________________________________________________________________________________________________________________________________________________</p><p>_____________________________________________________________________</p><p>_____________________________________________________________________</p><p>_____________________________________________________________________</p><p>Inteligência</p><p>________________________________________________________________________</p><p>______________________________________________________________________________________________________________________________________________________________________________________________________________</p><p>_______________________________________________________________________</p><p>Sensopercepção</p><p>( ) normal, ( ) Alucinação</p><p>Pensamento</p><p>( ) acelerado, ( )retardado, ( )fuga, ( ) bloqueio, ( ) prolixo, ( ) repetição</p><p>· Conteúdo: ( ) obsessões, ( ) hipocondrias, ( ) fobias, ( ) delírios</p><p>· expansão do eu: (grandeza, ciúme, reivindicação, genealógico, místico, de missão salvadora, deificação, erótico, de ciúmes, invenção ou reforma, idéias fantásticas, excessiva saúde, capacidade física, beleza...).</p><p>· retração do eu: (prejuízo, auto-referência, perseguição, influência, possessão, humildades, experiências apocalípticas).</p><p>· negação do eu: (hipocondríaco, negação e transformação corporal, auto-acusação, culpa, ruína, niilismo, tendência ao suicídio).</p><p>_____________________________________________________________________</p><p>_____________________________________________________________________</p><p>_____________________________________________________________________</p><p>_____________________________________________________________________</p><p>_____________________________________________________________________</p><p>Linguagem</p><p>( )disartrias (má articulação )</p><p>( )afasias, verbigeração (repetição de palavas)</p><p>( )parafasia (emprego inapropriado de palavras com sentidos parecidos)</p><p>( ) neologismo</p><p>( )mussitação (voz murmurada em tom baixo)</p><p>( )logorréia (fluxo incessante e incoercível de palavras)</p><p>( ) para-respostas (responde a uma indagação com algo que não tem nada a ver com o que foi perguntado)</p><p>Afetividade</p><p>_____________________________________________________________________</p><p>_____________________________________________________________________</p><p>_____________________________________________________________________</p><p>_____________________________________________________________________</p><p>Humor</p><p>( )normal; ( ) exaltado; ( )baixa de humor; ( )quebra súbita da tonalidade do humor durante a entrevista;</p><p>Consciência da doença atual</p><p>( ) sim, ( )parcialmente, ( ) não</p><p>HIPÓTESE DIAGNÓSTICA</p><p>_____________________________________________________________________</p><p>_____________________________________________________________________</p><p>__________________________________________________________________________________________________________________________________________</p><p>_____________________________________________________________________</p><p>_____________________________________________________________________</p><p>____________________________________________________________________________________________________________________________________________________________________________________________________________</p><p>_________________________________________________________________________________________________________________________________________</p>