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:____________________________________________________________
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Motivo da procura
______________________________________________________________________
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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
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Exames
(
) TC
) RM
) EEG
) Outro
Laudo:
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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
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Episdio anterior de AVE: (
) sim (
) no
Antecedentes Familiares
Histria da patologia na famlia: __________________________________________
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Dinmica familiar antes da leso: ___________________________________________
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Dinmica
familiar
___________________________________________________
atual:
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Linguagem e demais aspectos fonoaudiolgicos
Caractersticas anteriores: _________________________________________________
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Caractersticas
_____________________________________________________
atuais:
______________________________________________________________________
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Recursos utilizados para comunicao: (
(
) esforo para falar
) gestos
) escrita
) desenho
) mmica
) outros: ____________________________________________________________
Diferena
da
comunicao
________________________
com
) comunicao alternativa
famlia
com
os
demais:
______________________________________________________________________
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Leitura
e
_________________________________________________________
escrita:
______________________________________________________________________
Fala: __________________________________________________________________
______________________________________________________________________
Voz: __________________________________________________________________
______________________________________________________________________
Motricidade oral: ________________________________________________________
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Aspecto Motor
(
) paresia
) plegia
Membros
_______________________________________________________
afetados:
______________________________________________________________________
Dependncia em AVDs: (
(
) higiene
locomoo
) sim
) vesturio
(
(
) no
) alimentao
) tranferncias
Outras: ________________________________________________________________
______________________________________________________________________
Aspecto Psicolgico
Antes: ________________________________________________________________
______________________________________________________________________
Atualmente:____________________________________________________________
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Aspecto Sciocultural
Convvio social (amigos, trabalho): _________________________________________
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reas de interesse (hobby, lazer): ___________________________________________
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Rotina e atividades atuais: _________________________________________________
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Observaes:
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