Anamnese Adulto

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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:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Sintomas:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
3 – HISTÓRICO DA DOENÇA ATUAL:
Início da patologia:
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Tratamentos anteriores:
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Medicamentos:
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4 - HISTÓRICO PESSOAL:
Infância:
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Rotina:___________________________________________________________________________________________________________________________________________________________________________________________________________________________Vícios:_________________________________________________________________________________________________________________________________________________Hobbies:__________________________________________________________________________________________________________________________________________________________________________________________________________________________
Trabalho:_________________________________________________________________________________________________________________________________________________________________________________________________________________________
5 - HISTÓRICO FAMILIAR:
Pais:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Irmãos:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Cônjuge:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Filhos:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Lar:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Patológica Pregressa (enfermidades e tratamentos atuais e anteriores):
6 - EXAME PSÍQUICO:
Aparência:
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Comportamento:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Atitude para com o entrevistador:
( ) Cooperativo 
( ) Resistente 
( ) Indiferente
Orientação:
( ) Auto Identificatória 
( ) Corporal 
( ) Temporal 
( ) Espacial 
( ) Orientado em relação a patologia
Observações:
Atenção:__________________________________________________________________________________________________________________________________________________________________________________________________________________________
Vigilância:_________________________________________________________________________________________________________________________________________________________________________________________________________________________Tenacidade:_______________________________________________________________________________________________________________________________________________________________________________________________________________________Memória:_________________________________________________________________________________________________________________________________________________________________________________________________________________________
Inteligência:_______________________________________________________________________________________________________________________________________________________________________________________________________________________
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: _____________________________________________________________________
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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São Paulo ____de ___________ de 20__
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