Data do atendimento: ___/____/_______Identificao:

Nome:___________________________________________________________________Data de nasc. ___/___/____ Idade: ______ Sexo: _____ Estado Civil: ____________________ Grau de instruo:________________________ Profisso:_______________________________Endereo: _______________________________________________________________Telefones para contato: ____________________________________________________Religio:___________________________

Quem encaminhou? ____________________________________________________________________

Fez terapia anteriormente? (citar qual e quando)_______________________________________________________________________________________________________________________________Expectativas e objetivos do paciente:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Queixa Principal: _____________________________________________________________________________________________________________________________________________________________

Sintomas: ___________________________________________________________________________________________________________________________________________________________________

Medicamentos: No ( ) Sim ( ) (Quais?) _________________________________________________________________________________________________________________________________________

Histrico Pessoal:

Infncia:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Vida social: __________________________________________________________________________________________________________________________________________________________________Trabalho:____________________________________________________________________________________________________________________________________________________________________

Esquema Familiar: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Exame Psquico:Aparncia: ___________________________________________________________________________________________________________________________________________________________________

Comportamento: ______________________________________________________________________________________________________________________________________________________________

Pensamento ( ) acelerado, ( )retardado, ( )fuga, ( ) bloqueio, ( ) prolixo, ( ) repetio - Contedo: ( ) obsesses, ( ) hipocondrias, ( ) fobias, ( ) delrios -expanso do eu: (grandeza, cime, reivindicao, genealgico, mstico, de misso salvadora, deificao, ertico, de cimes, inveno ou reforma, idias fantsticas, excessiva sade, capacidade fsica, beleza...).-retrao do eu: (prejuzo, auto-referncia, perseguio, influncia, possesso, humildades, experincias apocalpticas).-negao do eu: (hipocondraco, negao e transformao corporal, auto-acusao, culpa, runa, niilismo, tendncia ao suicdio).__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Linguagem ( )disartrias (m articulao )( )afasias, verbigerao (repetio de palavas)( )parafasia (emprego inapropriado de palavras com sentidos parecidos)( ) neologismo ( )mussitao (voz murmurada em tom baixo)( ) logorria (fluxo incessante e incoercvel de palavras)( ) para-respostas (responde a uma indagao com algo que no tem nada a ver com o que foi perguntado)

Afetividade __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Humor ( )normal; ( ) exaltado; ( )baixa de humor; ( )quebra sbita da tonalidade do humor durante a entrevista;

Hiptese diagnstica ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Evoluo: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________