IDENTIFICAO

Nomedopaciente:____________________________________Datadehoje:_______
Nomedodepoente:_____________________________________________________
Relaocomopaciente:__________________________________________________
Telefonesdecontato:_____________________________________________________
Datadenascimento:______________________Idade:___________Sexo:_________
Localdenascimento:_____________________________________________________
Escolaridade:___________________________________________________________
Diagnsticomdico(sehouver):____________________________________________
Queixa:________________________________________________________________
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LEVANTAMENTODESINTOMAS
Preocupaesfsicas

oDoresdecabea
oTonturas
oEnjosouvmitos
oFadigaexcessiva
oIncontinnciaurinria/fecal
oProblemasintestinais
oFraquezadeumladodocorpo___________________(Indicarapartedocorpo)
oProblemascomacoordenao
oTremores
oTiquesoumovimentosestranhos
oProblemasdeequilbrio
oDesmaios
Sensrias

oPerdadesensaes/Dormncias(Indiqueolocal)__________________________
oFormigamentosousensaesestranhasnapele(Indiqueolocal)_______________
oDificuldadedediferenciarquenteefrio
oComprometimentovisual
oVcoisasquenoestol
oBrevesperodosdecegueira
oPerdaauditiva

oZumbidosnosouvidos
oEscutasonsestranhos
oDores(descreva)_____________________________________________________
PreocupaesIntelectuais

oDificuldadederesolverproblemasqueamaioriaconsegue
oDificuldadedepensarrapidamentequandonecessrio
oDificuldadedecompletaratividadesemtemporazovel
oDificuldadedefazercoisasseqencialmente
Linguagem
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Habilidadesnoverbais

oProblemasparaencontrarcaminhosemlugaresfamiliares
oDificuldadedereconhecerobjetosoupessoas
oDificuldadedereconhecerpartesdoprpriocorpo
oDificuldadedeorientaodotempo(dias,meses,ano)
oOutrosproblemasnoverbais__________________________________________
Memria

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Humor/Comportamento/Personalidade
Tristezaoudepresso____________________________
Ansiedadeounervosismo____________________________
Estresse____________________________
Problemasnosono[cochilo()/dormindomuito()]___________
Tempesadelosemumabasediria/semanal___________
Ficairritadofacilmente___________

Senteeuforia(sesentindonotopodomundo)___________
Sesentemuitoemotivo(chorandofacilmente)___________
Sesentecomosenadamaisimportasse___________
Ficafacilmentefrustrado___________
Fazcoisasautomaticamente(semconscincia)___________
Sesentemenosinibido(fazendocoisasquenofaziaantes)___________
Temdificuldadeemserespontneo___________
Houvemudananaenergia[perda()/aumento()]___________
Houvemudananoapetite[perda()/aumento()]___________
Houvemudananopeso[perda()/aumento()]___________
Houvemudananointeressesexual[aumento()/queda()]___________
Houvefaltadeinteresseematividadesprazerosas___________
Houveaumentodeirritabilidade___________
Houveaumentonaagressividade___________
Outrasmudanasnohumor,personalidadeouemcomolidacomaspessoas?
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Opacienteestpassandoporalgumproblemaemsuavidanosaspectosaseguir
listados?
Matrimonial/Familiar:
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Financeiro/Jurdico:
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Serviosdomsticos/Gerenciamentodedinheiro:
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Conduodeveculos:
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InciodosSintomas:_____________________________________________________
Sintomassedesenvolveram()vagarosamente()rapidamente
Seussintomasocorrem()devezemquando()freqentemente
Oqueparecequefazoproblemapiorar?
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HistricoMdico
Problemasmdicosapresentadosantesdacondioatualdopaciente:
Arteriosclerose
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Demncia
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Outrasinfecesnocrebrooudesordens(meningite,encefalite,privaode
oxignioetc)

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Diabetes
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Doenascardacas
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Cncer
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Doenasgraves/desordens(doenasimunolgicas,paralisiacerebral,plio,
pneumonia,etc)
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Exposiosubstnciatxica(ex:chumbo,solventes,qumicos)
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Grandescirurgias
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Problemaspsiquitricos
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Outros
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Opacientenormalmentetomamedicamentos?
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Opacientefezconsultaouestsobtratamentopsiquitrico?Sim()No()

Histricodousodesubstncias
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Histriadafamlia
Quantosirmosopacientetem?_____________________________________________
Temalgumproblemaemcomum(fsico,acadmico,psicolgico)associadocom
algumdosseusirmos?___________________________________________________
Relaocomafamlia:
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Estadocivil:____________________________________________________________
Quantosanosdecasado(a)tem:de__________at__________
Nomedo(a)esposo(a):___________________________________________________
Profissodo(a)esposo(a):________________________________________________
Sadedo(a)esposo(a):ExcelenteBoaRuim
Hcrianasemcasa:_____________________________________________________
Quemmaisatualmenteviveemcasa?________________________________________
Algummembrodafamliatemproblemadesadeounecessidadesespeciais
significantes?___________________________________________________________

HistricoProfissional
Opacientetrabalhaatualmente?()Sim()No
Opacientejseaposentou?()Sim()No
Cargooufunonotrabalho:__________________________________________

Lazer
Resumaostiposdelazerqueopacientegosta:_________________________________
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Eleaindacapazderealizarestasatividades?________________________________
Eletemalgumareligiooufreqentaalgumaigreja?SimNo
Sesim,qual?___________________________________________________________

HipteseDiagnstica:
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