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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!:___________________________________ 

Encaminhamento: _______________________________________________________ 

"#dico: _______________________________________________________________ 

$%ser&aç'es:____________________________________________________________  ______________________________________________________________________  ______________________________________________________________________ 

Motivo da procura

 ______________________________________________________________________  ______________________________________________________________________  ______________________________________________________________________  ______________________________________________________________________ 

H.P.D.A. (História Pregressa da Doença Atual)

Tipo de lesão: ( ! AE ( ! TCE ( ! Tmor ( ! Anerisma ( !Degenerati&a

$tro: _________________________________________________________________ 

Data: __________________________________________________________________ 

)ist*rico (In+cio, Internação, Coma, -ocal, Tempo, Complicaç'es, etc.!:

 ______________________________________________________________________  ______________________________________________________________________ 

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 ______________________________________________________________________  ______________________________________________________________________ 

Medicamentos

 ______________________________________________________________________  ______________________________________________________________________  ______________________________________________________________________  ______________________________________________________________________ 

Exames

( ! TC ( ! " ( ! EE0 ( ! $tro

-ado: ______________________________________________________________________  ______________________________________________________________________  ______________________________________________________________________ 

equelas ou alteraç!es o"servadas

( ! consci1ncia ( ! 2adro motor ( ! prodção ( ! percepção

( ! alimentação ( ! atenção ( ! compreensão ( ! adição

( ! fala ( ! incontin1ncia ( ! mem*ria ( ! &isão

Antecedentes #ndividuais

Ati&idades profissionais: __________________________________________________ 

 ______________________________________________________________________  ______________________________________________________________________ 

3a4de geral: ( ! pro%lemas card+acos ( ! dia%etes ( ! hipertensão

( ! etilismo ( ! ta%agismo ( ! drogas ( ! otros

 ______________________________________________________________________  ______________________________________________________________________ 

Epis*dio anterior de AE: ( ! sim ( ! não

Antecedentes $amiliares

)ist*ria da patologia na fam+lia: __________________________________________ 

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 ______________________________________________________________________  ______________________________________________________________________ 

Din5mica familiar antes da lesão: ___________________________________________ 

 ______________________________________________________________________  ______________________________________________________________________ 

Din5mica familiar atal: ___________________________________________________ 

 ______________________________________________________________________  ______________________________________________________________________ 

%inguagem e demais aspectos fonoaudiológicos

Caracter+sticas anteriores: _________________________________________________ 

 ______________________________________________________________________  ______________________________________________________________________ 

Caracter+sticas atais: _____________________________________________________ 

 ______________________________________________________________________  ______________________________________________________________________  ______________________________________________________________________ 

ecrsos tili6ados para comnicação: ( ! gestos ( ! escrita ( ! desenho

( ! m+mica ( ! esforço para falar ( ! comnicação alternati&a

( ! otros: ____________________________________________________________ 

Diferença da comnicação com a fam+lia e com os demais: ________________________ 

 ______________________________________________________________________  ______________________________________________________________________ 

-eitra e escrita: _________________________________________________________ 

 ______________________________________________________________________ 

7ala: __________________________________________________________________ 

 ______________________________________________________________________ 

o6: __________________________________________________________________ 

 ______________________________________________________________________ 

"otricidade oral: ________________________________________________________ 

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 ______________________________________________________________________ 

Aspecto Motor

( ! paresia ( ! plegia"em%ros afetados:

 _______________________________________________________ 

 ______________________________________________________________________ 

Depend1ncia em ADs: ( ! sim ( ! não

( ! higiene ( ! &est8rio ( ! alimentação ( ! tranfer1ncias ( !locomoção

$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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 ______________________________________________________________________  ______________________________________________________________________  ______________________________________________________________________  ______________________________________________________________________  ______________________________________________________________________ 

 ______________________________________________________________________  ______________________________________________________________________  ______________________________________________________________________  ______________________________________________________________________  ______________________________________________________________________  ______________________________________________________________________  ______________________________________________________________________