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Protocolo de anamnese para patologias neurológicas adquiridas na fase adulta
Dados Pessoais
Nome: _______________________ ___________________________________ _______________________ _______________________ ___________________ _______ Data de Nascimento: ________ / _________ / __________ Idade: _______________________ ___________________________________ _______________________ _______________________ ___________________ _______ Endereço: _______________________ ___________________________________ _______________________ _______________________ ________________ ____ Cidade: ______________________ _________________________________ _______________________ _______________________ ___________________ ________ Estado: ______________________ __________________________________ _______________________ _______________________ ___________________ _______ Telefone: ______________________________________________________________ Escolaridade: ______________________ __________________________________ _______________________ _______________________ ______________ __ Profissão: ______________________ _________________________________ _______________________ _______________________ _________________ ______ Acompanhante (nome e gra de parentesco!:_________________________ parentesco!:___________________________________ __________ Encaminhamento: Encaminhamento: _______________________ ___________________________________ _______________________ ____________________ _________ "#dico: _______________________ __________________________________ _______________________ _______________________ _________________ ______ $%ser&aç'es:____________________________________________________________ _______________________ ___________________________________ _______________________ _______________________ _______________________ ____________ _ _______________________ ___________________________________ _______________________ _______________________ _______________________ ____________ _
Motivo da procura
_______________________ ___________________________________ _______________________ _______________________ _______________________ ____________ _ _______________________ ___________________________________ _______________________ _______________________ _______________________ ____________ _ _______________________ ___________________________________ _______________________ _______________________ _______________________ ____________ _ _______________________ ___________________________________ _______________________ _______________________ _______________________ ____________ _
H.P.D.A. H.P.D.A. (História Pregressa da Doença Atual)
Tipo Tipo de lesão: lesão: ( Degenerati&a
! AE (
! TCE (
! Tmor Tmor (
! Ane Anerism rismaa
(
!
$tro: _______________________ __________________________________ _______________________ _______________________ ___________________ ________ Data: _______________________ __________________________________ _______________________ _______________________ ____________________ _________ )ist )ist*r *ric icoo (In+ (In+ci cio, o, Inte Intern rnaç ação ão,, Co Coma ma,, -oca -ocal, l, Tempo, po, Co Comp mpli lica caç' ç'es es,, etc. etc.!: !: _______________________ ___________________________________ _______________________ _______________________ _______________________ ____________ _ _______________________ ___________________________________ _______________________ _______________________ _______________________ ____________ _
______________________________________________________________________ ______________________________________________________________________
Medicamentos
______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________
Exames
(
! TC
(
! "
(
! EE0
(
! $tro
-ado: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________
equelas ou alteraç!es o"servadas
(
! consci1ncia
(
! alimentação
(
! fala
(
(
! 2adro motor (
! atenção
! incontin1ncia
(
( (
! prodção
(
! percepção
! compreensão
(
! adição
! mem*ria
(
! &isão
Antecedentes #ndividuais
Ati&idades profissionais: __________________________________________________ ______________________________________________________________________ ______________________________________________________________________ 3a4de geral: (
! pro%lemas card+acos
(
(
! etilismo
! ta%agismo
(
(
! dia%etes
! drogas
(
(
! hipertensão
! otros
______________________________________________________________________ ______________________________________________________________________ Epis*dio anterior de AE: (
! sim (
! não
Antecedentes $amiliares
)ist*ria da patologia na fam+lia: __________________________________________
______________________________________________________________________ ______________________________________________________________________ Din5mica familiar antes da lesão: ___________________________________________ ______________________________________________________________________ ______________________________________________________________________ Din5mica familiar ___________________________________________________
atal:
______________________________________________________________________ ______________________________________________________________________
%inguagem e demais aspectos fonoaudiológicos
Caracter+sticas anteriores: _________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Caracter+sticas _____________________________________________________
atais:
______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ecrsos tili6ados para comnicação: ( (
! esforço para falar
! gestos
! escrita
(
! desenho
(
! m+mica
(
! otros: ____________________________________________________________
Diferença da comnicação ________________________
com
(
(
a
! comnicação alternati&a fam+lia
e
com
os
demais:
______________________________________________________________________ ______________________________________________________________________ -eitra e _________________________________________________________
escrita:
______________________________________________________________________ 7ala: __________________________________________________________________ ______________________________________________________________________ o6: __________________________________________________________________ ______________________________________________________________________ "otricidade oral: ________________________________________________________
______________________________________________________________________
Aspecto Motor
(
! paresia
(
! plegia
"em%ros _______________________________________________________
afetados:
______________________________________________________________________ Depend1ncia em ADs: ( ( ! higiene locomoção
(
! sim
! &est8rio
( (
! não ! alimentação
(
! tranfer1ncias
(
!
$tras: ________________________________________________________________ ______________________________________________________________________
Aspecto Psicológico
Antes: ________________________________________________________________ ______________________________________________________________________ Atalmente:____________________________________________________________ ______________________________________________________________________
Aspecto óciocultural
Con&+&io social (amigos, tra%alho!: _________________________________________ ______________________________________________________________________ ______________________________________________________________________ 9reas de interesse (ho%%, la6er!: ___________________________________________ ______________________________________________________________________ ______________________________________________________________________ otina e ati&idades atais: _________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________
&"servaç!es'
___________________________________________________________
______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________
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