AFASIA-anamnese.docx

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

! AE (

! TCE (

! Tmor Tmor (

! Ane Anerism 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

-ado:  ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________ 

equelas ou alteraç!es o"servadas

(

! consci1ncia

(

! alimentação

(

! fala

(

(

! 2adro motor (

! atenção

! incontin1ncia

(

( (

! prodção

(

! percepção

! compreensão

(

! adição

! mem*ria

(

! &isão

Antecedentes #ndividuais

Ati&idades profissionais: __________________________________________________   ______________________________________________________________________   ______________________________________________________________________  3a4de geral: (

! pro%lemas card+acos

(

(

! etilismo

! ta%agismo

(

(

! dia%etes

! drogas

(

(

! hipertensão

! otros

 ______________________________________________________________________   ______________________________________________________________________  Epis*dio anterior de AE: (

! sim (

! não

Antecedentes $amiliares

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

 ______________________________________________________________________   ______________________________________________________________________  Din5mica familiar antes da lesão: ___________________________________________   ______________________________________________________________________   ______________________________________________________________________  Din5mica familiar  ___________________________________________________ 

atal:

 ______________________________________________________________________   ______________________________________________________________________ 

%inguagem e demais aspectos fonoaudiológicos

Caracter+sticas anteriores: _________________________________________________   ______________________________________________________________________   ______________________________________________________________________  Caracter+sticas  _____________________________________________________ 

atais:

 ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________  ecrsos tili6ados para comnicação: ( (

! esforço para falar

! gestos

! escrita

(

! desenho

(

! m+mica

(

! otros: ____________________________________________________________ 

Diferença da comnicação  ________________________ 

com

(

(

a

! comnicação alternati&a fam+lia

e

com

os

demais:

 ______________________________________________________________________   ______________________________________________________________________  -eitra e  _________________________________________________________ 

escrita:

 ______________________________________________________________________  7ala: __________________________________________________________________   ______________________________________________________________________  o6: __________________________________________________________________   ______________________________________________________________________  "otricidade oral: ________________________________________________________ 

 ______________________________________________________________________ 

Aspecto Motor

(

! paresia

(

! plegia

"em%ros  _______________________________________________________ 

afetados:

 ______________________________________________________________________  Depend1ncia em ADs: ( ( ! higiene locomoção

(

! sim

! &est8rio

( (

! não ! alimentação

(

! tranfer1ncias

(

!

$tras: ________________________________________________________________   ______________________________________________________________________ 

Aspecto Psicológico

Antes: ________________________________________________________________   ______________________________________________________________________  Atalmente:____________________________________________________________   ______________________________________________________________________ 

Aspecto óciocultural

Con&+&io social (amigos, tra%alho!: _________________________________________   ______________________________________________________________________   ______________________________________________________________________  9reas de interesse (ho%%, la6er!: ___________________________________________   ______________________________________________________________________   ______________________________________________________________________  otina e ati&idades atais: _________________________________________________   ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________ 

&"servaç!es'

 ___________________________________________________________ 

 ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________   ______________________________________________________________________