Data do atendimento: _________________________________________________

Identificação

Nome:______________________________________________________________
Idade: __________Sexo: _____________ Nacionalidade: _____________________
Estado Civil: ____________________ Data de nasc.:__________________________
Grau de instrução:_____________________________________________________
Profissão:___________________________________________________________
Residência (cidade/estado): _____________________________________________
Telefones para contado: __________________________________

Atendimento
Frequência:___________________________ Data/hora:______________________

Queixa Principal:
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Secundária:
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Sintomas:
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Histórico da Doença Atual

Início da patologia:
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Frequencia__________________________________________________________
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Intensidade:_________________________________________________________
Tratamentos anteriores: _______________________________________________
Medicamentos:_______________________________________________________
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Histórico Pessoal

Infância:____________________________________________________________
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Rotina:_____________________________________________________________
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Vicios:______________________________________________________________
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Hobbies:____________________________________________________________
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Trabalho:____________________________________________________________
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Histórico Familiar
Pais:_______________________________________________________________
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Irmaos:_____________________________________________________________
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Conjugue:___________________________________________________________
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Filhos:______________________________________________________________
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Lar:________________________________________________________________
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História Patológicas Pregressa (enfermidades e tratamentos atuais e anteriores):

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Exame Psíquico
Aparências:
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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
Vigilância:___________________________________________________________
Tenacidade:_________________________________________________________

Memória
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Inteligência
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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, ideias 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, autoacusação,
culpa, ruína, niilismo, tendência ao suicídio).
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Linguagem
( ) dispartiras (má articulação )
( ) afasias, verbigeração (repetição de palavras)
( ) parafasia (emprego inapropriado de palavras com sentidos parecidos)
( ) neologismo
( ) mussitação (voz murmurada em tom baixo)
( ) lograria (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

HIPÓTESE DIAGNÓSTICA
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