ENTREVISTA DE ANAMNESE - ADULTO _______/______/______

• IDENTIFICAÇÃO

Nome:___________________________________________________________________ Idade: __________

Sexo: _________________ Nacionalidade: ____________________ Estado civil: _______________________

Data de nascimento: ____/______/_______ Escolaridade:________________ Profissão: ________________

Residência:____________ ________________________________________ Tel: (___)__________________

Email: ___________________________________________________________________________________

• Queixa Principal:

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•Secundária:

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• Sintomas:

Situações

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Cognitivo

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Comportamental

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Físicos

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Histórico da queixa Atual:

Início:

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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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• Atualmente:

Rotina atual

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Vícios:

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Hobbies:

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Trabalho:

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Religião:

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Estudo:

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Relacionamento:

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Família:

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Social:

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Histórico Familiar:

Pais:

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Irmãos:

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Conjugue:

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Filhos:

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Lar:

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

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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:__________________________________________________________________________________
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Atenção:

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Memória:

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Linguagem:

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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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Afetividade:

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Humor

( ) Normal ( ) Exaltado ( ) Baixa de humor ( ) Mudança súbita do humor durante a entrevista;

Consciência da doença atual:

( ) Sim ( ) Parcialmente ( ) Não

HIPÓTESE DIAGNÓSTICA

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Observações:
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