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

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

1
 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: ______________________________________________________
____________________________________________________________
____________________________________________________________

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: __________________________________________________

________________________________________________________________
________________________________________________________________

Motivo do pedido, segundo o doente: __________________________________

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Preocupaes actuais do doente: ______________________________________

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

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

2
 Neuropsicologia e Psicologia Clnica

6. Histria clnica:

Inicio da Leso/ tempo de evoluo: ___________________________________

________________________________________________________________
________________________________________________________________

Evoluo da doena/cronologia dos acontecimentos: ______________________

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

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

________________________________________________________________
________________________________________________________________
________________________________________________________________

Sinais neurolgicos actuais: __________________________________________

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Uso de culos, aparelhos auditivos, outros: _____________________________

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

desconhecida) _______________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Localizao e extenso da leso: ______________________________________

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Exames auxiliares de diagnstico:

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

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

3
 Neuropsicologia e Psicologia Clnica

Medicao actual: __________________________________________________

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Doenas actuais: __________________________________________________

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Antecedentes neurolgicos: __________________________________________

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Outros antecedentes clnicos: ________________________________________

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Antecedentes Psiquitricos ou de ordem emocional ________________________

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

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

4
 Neuropsicologia e Psicologia Clnica

Dados relevantes da infncia/adolescncia: ______________________________

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Antecedentes familiares de doenas: ___________________________________

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Queixas clnicas:

Sintomas ou alteraes fsicas: _______________________________________

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

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

5
 Neuropsicologia e Psicologia Clnica

Sintomas ou alteraes comportamentais: ______________________________

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Queixas cognitivas: ________________________________________________

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Preocupaes psicossociais: __________________________________________

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

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

6
 Neuropsicologia e Psicologia Clnica

Todas estas dificuldades esto estveis ou h declnio progressivo? ___________

________________________________________________________________
________________________________________________________________
________________________________________________________________

Conscincia e Consequncias das dificuldades:

Conscincia das dificuldades (anosognosia, preocupado, indiferente) _______________

________________________________________________________________
________________________________________________________________
________________________________________________________________

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

rotina) __________________________________________________________
________________________________________________________________

Qual a frequncia da ocorrncia das dificuldades? _________________________

________________________________________________________________

Qual o impacto das dificuldades sentidas na vida profissional? _______________

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Qual o impacto das dificuldades sentidas na vida familiar? _______________

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Qual o impacto das dificuldades sentidas na vida quotidiana? _______________

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Mecanismos compensatrios: _________________________________________

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

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

7
 Neuropsicologia e Psicologia Clnica

Mecanismos de negao ou paliativos: _________________________________

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Qual a atribuio causal que o doente faz para a ocorrncia das dificuldades? ___
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Outras observaes:

O doente apresenta-se consulta sozinho ou acompanhado:________________

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Aparncia geral: ___________________________________________________

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Actividade motora: _________________________________________________

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Humor: __________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

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

8
 Neuropsicologia e Psicologia Clnica

Ansiedade: _______________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Grau de cooperao: _______________________________________________

________________________________________________________________
________________________________________________________________
________________________________________________________________

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 _________________________________________________________
________________________________________________________________

Perde objectos ____________________________________________________

________________________________________________________________

Reconhece faces familiares __________________________________________

________________________________________________________________

Reconhece nomes __________________________________________________

________________________________________________________________

Esquece compromissos _____________________________________________

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

9
 Neuropsicologia e Psicologia Clnica

________________________________________________________________

Memria a longo prazo ______________________________________________

________________________________________________________________

Praxias:

Observaes clnicas/queixas: ________________________________________

________________________________________________________________

Mmica (tesoura, pentear, tomar ch) ______________________________________

________________________________________________________________

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

10
 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: __________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

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

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

11
 Neuropsicologia e Psicologia Clnica

Primeiras alteraes notadas: ________________________________________

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Ms: ________________ Ano:_________________

Primeira pessoa a aperceber-se: ______________________________________

________________________________________________________________

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

Alteraes seguintes: _______________________________________________

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

OBSERVAES: __________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

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

12