Data do atendimento: ____________________________________________________ Identificação: Nome:___________________________________________________________________ Idade: __________Sexo: _________________ Nacionalidade: ______________________ Estado Civil: ____________________ Data de nasc.:______________________________ Grau de instrução:__________________________________________________________ Profissão:________________________________________________________________ Residência (cidade/estado): __________________________________________________ Telefones para contado: _____________________________________________________ Atendimento: Frequencia:___________________________ Data/hora:___________________________ Queixa Principal: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ Secundária: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Sintomas: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ___________________________________________ Histórico da Doença Atual: Início da patologia: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Frequência:_______________________________________________________________ ________________________________________________________________________ Intensidade:______________________________________________________________ Tratamentos anteriores: ____________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ Medicamentos:____________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ Histórico Pessoal: Infância:__________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ Rotina___________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Vícios:___________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ Hobbies:_________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ Trabalho:_________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Historico Familiar: Pais:____________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Irmaos:__________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ Conjugue:________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ Filhos:___________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ Lar:_____________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ Historia Patológica Pregressa (enfermidades e tratamentos atuais e anteriores): ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________ Exame Psíquico: Aparência: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 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 ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Sensopercepção ( ) 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, idéias fantásticas, excessiva saúde, capacidade física, beleza...). - retração do eu: (prejuízo, auto-referência, perseguição, influência, possessão, humildades, experiências apocalípticas). - negação do eu: (hipocondríaco, negação e transformação corporal, auto-acusação, culpa, ruína, niilismo, tendência ao suicídio). ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Linguagem ( )disartrias (má articulação ) ( )afasias, verbigeração (repetição de palavas) ( )parafasia (emprego inapropriado de palavras com sentidos parecidos) ( ) 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 ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Humor ( )normal; ( ) exaltado; ( )baixa de humor; ( )quebra súbita da tonalidade do humor durante a entrevista; Consciência da doença atual ( ) sim, ( )parcialmente, ( ) não HIPÓTESE DIAGNÓSTICA ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________
