A Anamnese Adulto

Data do atendimento: ____________________________________________________

Identificação:

Nome:___________________________________________________________________

Idade: __________Sexo: _________________ Nacionalidade: ______________________

Estado Civil: ____________________ Data de nasc.:______________________________

Grau de instrução:__________________________________________________________

Profissão:________________________________________________________________

Residência (cidade/estado): __________________________________________________

Telefones para contado: _____________________________________________________

Atendimento:

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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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Frequência:_______________________________________________________________________________________________________________________________________

Intensidade:______________________________________________________________

Tratamentos anteriores: ____________________________________________________

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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