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Neuropsicologia e Psicologia Clnica

Entrevista de Anamnese
Hora de incio:________ Hora de Fim: __________ Data: _____________

Nmero do processo: Examinador/Tcnico: ____________

Parte I Dados referentes ao doente

1. Dados pessoais:

Nome: __________________________________________________________

Idade: ________ Data de nascimento: ________________ Sexo: M F__

Morada: ________________________________________________________

Contacto Telefnico: ________________________

Naturalidade: ______________________ Lngua Me: ___________________

Dominncia Manual/Lateralidade: _____________________________________

Estado civil (actual): ____________________ H quanto tempo: ___________

Filhos: Sim__ No__

Nome: ___________________________________ Idade: _________


Nome: ___________________________________ Idade: _________
Nome: ___________________________________ Idade: _________
Nome: ___________________________________ Idade: _________
Nome: ___________________________________ Idade: _________

(Potencial) Cuidador principal do doente: __________________________

Grau de parentesco do inquirido com o cuidador: _________________

2. Dados acadmicos:

Escolaridade: _________________________________________

Idade incio escolaridade: __________ Idade fim escolaridade: ___________

Lnguas estrangeiras: _____________________________________

Carta de conduo: Sim_____ No_____

No caso de ser analfabeto:


Assina o nome Sim No
Conhece as horas Sim No
Faz clculo mental Sim No
L algarismos Sim No
Escreve algarismos Sim No
Faz telefonemas Sim No

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Neuropsicologia e Psicologia Clnica

Atende o telefone e fica com recados Sim No


Movimenta conta bancria Sim No
Viaja s e ou de transporte pblico Sim No
Faz compras Sim No

3. Dados profissionais:

Profisso1: ____________________ Idade: ________________________

Profisso2: _____________________ Idade: ________________________

Reformado: Sim____ No____ Com que idade: ______________________

Motivo: ______________________________________________________
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4. Hbitos e actividades extra-profissionais em adulto

Hbitos de leitura: Sim No Quais: __________________


Hbitos de escrita: Sim No Quais: __________________
Clculo mental: Sim No Quais: __________________
Clculo escrito: Sim No Quais: __________________
Desenho: Sim No Quais: __________________
Hobbies: Sim No Quais: __________________

5. Motivo do pedido da consulta:

Quem fez o pedido: ________________________________________________

Mdicos responsveis pelo doente:


Mdico de Famlia: ________________
Neurologista: ____________________
Psiquiatra: ______________________
Outro: _________________________

Motivo do pedido: __________________________________________________


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Motivo do pedido, segundo o doente: __________________________________


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Preocupaes actuais do doente: ______________________________________


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Neuropsicologia e Psicologia Clnica

6. Histria clnica:

Inicio da Leso/ tempo de evoluo: ___________________________________


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Evoluo da doena/cronologia dos acontecimentos: ______________________


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Caractersticas da evoluo (melhorias, declnio progressivo, estabilidade) ___________


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Sinais neurolgicos actuais: __________________________________________


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Uso de culos, aparelhos auditivos, outros: _____________________________

Natureza/etiologia da Leso cerebral (vascular, TCE, Tumor, Epilepsia, infecciosa,


desconhecida) _______________________________________________________
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Localizao e extenso da leso: ______________________________________


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Exames auxiliares de diagnstico:


Audio e ou Viso
TAC
RM
EEG
ECG
Psicolgico ou psiquitrico
Neuropsicolgico
Fala
Outros: _____________________________________________________

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Neuropsicologia e Psicologia Clnica

Medicao actual: __________________________________________________


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Doenas actuais: __________________________________________________


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Antecedentes neurolgicos: __________________________________________


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Outros antecedentes clnicos: ________________________________________


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Antecedentes Psiquitricos ou de ordem emocional ________________________


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e-mail:snpsicologia@gmail.com tlm: 938 291 757

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Neuropsicologia e Psicologia Clnica

Dados relevantes da infncia/adolescncia: ______________________________


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Antecedentes familiares de doenas: ___________________________________


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Queixas clnicas:

Sintomas ou alteraes fsicas: _______________________________________


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Neuropsicologia e Psicologia Clnica

Sintomas ou alteraes comportamentais: ______________________________


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Queixas cognitivas: ________________________________________________


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Preocupaes psicossociais: __________________________________________


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Neuropsicologia e Psicologia Clnica

Todas estas dificuldades esto estveis ou h declnio progressivo? ___________


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Conscincia e Consequncias das dificuldades:

Conscincia das dificuldades (anosognosia, preocupado, indiferente) _______________


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As situaes de ocorrncia das dificuldades (manh, tarde, quando fatigado, sobrecarga,


rotina) __________________________________________________________
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Qual a frequncia da ocorrncia das dificuldades? _________________________


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Qual o impacto das dificuldades sentidas na vida profissional? _______________


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Qual o impacto das dificuldades sentidas na vida familiar? _______________


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Qual o impacto das dificuldades sentidas na vida quotidiana? _______________


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Mecanismos compensatrios: _________________________________________


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Neuropsicologia e Psicologia Clnica

Mecanismos de negao ou paliativos: _________________________________


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Qual a atribuio causal que o doente faz para a ocorrncia das dificuldades? ___
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Outras observaes:

O doente apresenta-se consulta sozinho ou acompanhado:________________


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Aparncia geral: ___________________________________________________


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Actividade motora: _________________________________________________


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Humor: __________________________________________________________
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e-mail:snpsicologia@gmail.com tlm: 938 291 757

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Neuropsicologia e Psicologia Clnica

Ansiedade: _______________________________________________________
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Grau de cooperao: _______________________________________________


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Reflexos Direita Esquerda


Palmomentoniano
Agarrar (preenso)
Glabellar tap (A torneira glabelar)
Oral (snout/focinho)

Coordenao Motora Grossa Direita Esquerda


Pernas: fora muscular; hemiparsias;
espasticidade; bengala; coxear
Braos: fora muscular; hemiparsias;
espasticidade; fora a segurar
Face: tiques; assimetria; parelisia

Coordenao Motora fina Direita Esquerda


Desteridade
Tremores
Dysdiadokinesia: Dedo-nariz
Dedo-Polegar
Flat/first/side

Memria:

Amnsia _________________________________________________________
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Perde objectos ____________________________________________________


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Reconhece faces familiares __________________________________________


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Reconhece nomes __________________________________________________


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Esquece compromissos _____________________________________________

e-mail:snpsicologia@gmail.com tlm: 938 291 757

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Neuropsicologia e Psicologia Clnica

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Memria a longo prazo ______________________________________________


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Praxias:

Observaes clnicas/queixas: ________________________________________


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Mmica (tesoura, pentear, tomar ch) ______________________________________


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Parte II Dados referentes ao cuidador

1. Dados pessoais:

Nome: ____________________________________________________

Idade: _________ Data de Nascimento: ______________ Sexo: M__ F__

Filhos: Sim__ No__

Nome: ___________________________________ Idade: _________


Nome: ___________________________________ Idade: _________
Nome: ___________________________________ Idade: _________
Nome: ___________________________________ Idade: _________
Nome: ___________________________________ Idade: _________

Morada: _________________________________________________________

Cuidador principal do doente? ________________________________________

Grau de parentesco com o doente: ____________________________________

2. Dados acadmicos:

Escolaridade: _____________________________________________________

Idade incio escolaridade: __________ Idade fim escolaridade: _________

Lnguas estrangeiras: _________________________________________

Carta de conduo: Sim___ No____

No caso de ser analfabeto:

e-mail:snpsicologia@gmail.com tlm: 938 291 757

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Neuropsicologia e Psicologia Clnica

Assina o nome Sim No


Conhece as horas Sim No
Faz clculo mental Sim No
L algarismos Sim No
Escreve algarismos Sim No
Faz telefonemas Sim No
Atende o telefone e fica com recados Sim No
Movimenta conta bancria Sim No
Viaja s e ou de transporte pblico Sim No
Faz compras Sim No

3. Dados profissionais

Profisso 1: ____________________ Idade: ________________________

Profisso 2: ____________________ Idade: ________________________

Reformado: Sim__ No__ Com que idade: __________________

Motivo: __________________________________________________________
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4. Hbitos e actividades extra-profissionais em adulto

Hbitos de leitura: Sim No Quais: _______________


Hbitos de escrita: Sim No Quais: _______________
Clculo mental: Sim No Quais: ________________
Clculo escrito: Sim No Quais: ________________
Desenho: Sim No Quais: _________________
Hobbies: Sim No Quais: _________________

Parte III Dados referentes relao doente/famlia

O seu familiar doente habitava consigo quando comearam os primeiros


sintomas? Sim____ No____

Se no: Moravam em casas prximas? Sim___ no___

Na mesma localidade? Sim___ no____

Visitava o seu familiar, todos os dias? Sim____ no____

Semanas_______ quinzenas______ meses_______

Parte IV Dados referentes ao incio da doena do seu familiar

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Neuropsicologia e Psicologia Clnica

Primeiras alteraes notadas: ________________________________________


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Ms: ________________ Ano:_________________

Primeira pessoa a aperceber-se: ______________________________________


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Quando se queixou ao Mdico de Famlia (ms e ano): ________________

Alteraes seguintes: _______________________________________________


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OBSERVAES: __________________________________________________
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e-mail:snpsicologia@gmail.com tlm: 938 291 757

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