Protocolo de anamnese para patologias neurolgicas adquiridas na fase adulta

Dados Pessoais
Nome:
_________________________________________________________________
Data de Nascimento: ________ / _________ / __________
Idade: _________________________________________________________________
Endereo: ______________________________________________________________
Cidade: ________________________________________________________________
Estado: ________________________________________________________________
Telefone: ______________________________________________________________
Escolaridade: ___________________________________________________________
Profisso: ______________________________________________________________
Acompanhante (nome e grau de parentesco):___________________________________
Encaminhamento: _______________________________________________________
Mdico: _______________________________________________________________
Observaes:____________________________________________________________
______________________________________________________________________
______________________________________________________________________

Motivo da procura
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

H.P.D.A. (Histria Pregressa da Doena Atual)

Tipo de leso: (
Degenerativa

) AVE

) TCE

) Tumor

) Aneurisma

Outro: _________________________________________________________________
Data: __________________________________________________________________
Histrico (Incio, Internao, Coma, Local, Tempo, Complicaes, etc.):
______________________________________________________________________
______________________________________________________________________

______________________________________________________________________
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Medicamentos
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Exames
(

) TC

) RM

) EEG

) Outro

Laudo:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Sequelas ou alteraes observadas

(

) conscincia

) alimentao

) fala

) quadro motor
(

) ateno

) incontinncia

(
(

) produo

) percepo

) compreenso

) audio

) memria

) viso

Antecedentes Individuais
Atividades profissionais: __________________________________________________
______________________________________________________________________
______________________________________________________________________
Sade geral: (

) problemas cardacos

) etilismo

) tabagismo

) diabetes

) drogas

) hipertenso

) outros

______________________________________________________________________
______________________________________________________________________
Episdio anterior de AVE: (

) sim (

) no

Antecedentes Familiares
Histria da patologia na famlia: __________________________________________

______________________________________________________________________
______________________________________________________________________
Dinmica familiar antes da leso: ___________________________________________
______________________________________________________________________
______________________________________________________________________
Dinmica
familiar
___________________________________________________

atual:

______________________________________________________________________
______________________________________________________________________

Linguagem e demais aspectos fonoaudiolgicos

Caractersticas anteriores: _________________________________________________
______________________________________________________________________
______________________________________________________________________
Caractersticas
_____________________________________________________

atuais:

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Recursos utilizados para comunicao: (
(

) esforo para falar

) gestos

) escrita

) desenho

) mmica

) outros: ____________________________________________________________

Diferena
da
comunicao
________________________

com

) comunicao alternativa

famlia

com

os

demais:

______________________________________________________________________
______________________________________________________________________
Leitura
e
_________________________________________________________

escrita:

______________________________________________________________________
Fala: __________________________________________________________________
______________________________________________________________________
Voz: __________________________________________________________________
______________________________________________________________________
Motricidade oral: ________________________________________________________

______________________________________________________________________

Aspecto Motor
(

) paresia

) plegia

Membros
_______________________________________________________

afetados:

______________________________________________________________________
Dependncia em AVDs: (
(
) higiene
locomoo

) sim

) vesturio

(
(

) no
) alimentao

) tranferncias

Outras: ________________________________________________________________
______________________________________________________________________

Aspecto Psicolgico
Antes: ________________________________________________________________
______________________________________________________________________
Atualmente:____________________________________________________________
______________________________________________________________________

Aspecto Sciocultural
Convvio social (amigos, trabalho): _________________________________________
______________________________________________________________________
______________________________________________________________________
reas de interesse (hobby, lazer): ___________________________________________
______________________________________________________________________
______________________________________________________________________
Rotina e atividades atuais: _________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Observaes:
___________________________________________________________

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