AFASIA Anamnese

 

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: Encaminhamen to: ____________ _______________________ _______________________ _______________________ ____________________  _________  "#dico: ___________ _______________________ _______________________ _______________________ _______________________ _________________  ______  $%ser&aç'es:____________________________________________________________   _______________________  ____________ _______________________ _______________________ _______________________ _______________________ ____________  _   _______________________  ____________ _______________________ _______________________ _______________________ _______________________ ____________  _ 

Motivo da procura

 ___________________________________  _______________________ _______________________ _______________________ _______________________ ____________  _   _______________________  ____________ _______________________ _______________________ _______________________ _______________________ ____________  _   _______________________  ____________ _______________________ _______________________ _______________________ _______________________ ____________  _   _______________________  ____________ _______________________ _______________________ _______________________ _______________________ ____________  _ 

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

Tipo de lesão: Tipo lesão: ( Degenerati&a

! AE (

! TCE (

! T Tmor mor (

! Ane Anerism rismaa

(

!

$tro: _______________________ __________________________________ _______________________ _______________________ ___________________  ________  Data: _______________________ __________________________________ _______________________ _______________________ ____________________  _________  )ist )ist*r *ric icoo (In+ (In+ci cio, o, Inte Intern rnaç ação ão,, Coma Coma,, -oca -ocal, l, Tempo po,, Co Comp mpli lica caç' ç'es es,, et etc. c.!: !:  _______________________  ____________ _______________________ _______________________ _______________________ _______________________ ____________  _   _______________________  ____________ _______________________ _______________________ _______________________ _______________________ ____________  _ 

 

 ___________________________________  _______________________ _______________________ _______________________ _______________________ ____________  _   _______________________  ____________ _______________________ _______________________ _______________________ _______________________ ____________  _ 

Medicamentos

 ___________________________________  _______________________ _______________________ _______________________ _______________________ ____________  _   _______________________  ____________ _______________________ _______________________ _______________________ _______________________ ____________  _   _______________________  ____________ _______________________ _______________________ _______________________ _______________________ ____________  _   _______________________  ____________ _______________________ _______________________ _______________________ _______________________ ____________  _ 

Exames

(

! TC

(

! "

(

! EE0

(

! $tro

-ado:  _______________________  ____________ _______________________ _______________________ _______________________ _______________________ ____________  _   _______________________  ____________ _______________________ _______________________ _______________________ _______________________ ____________  _   _______________________  ____________ _______________________ _______________________ _______________________ _______________________ ____________  _ 

equelas ou alteraç!es o"servadas

(

! consci1ncia

(

! alimentação

(

! fala

(

(

! 2adro motor (

! atenção

! incontin1ncia

(

( (

! prodção

(

! percepção

! compreensã compreensãoo

(

! 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nicaçã comnicação: o: ( (

! 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:

 ___________________________________  _______________________ _______________________ ____________________  _________   _______________________  ____________ _______________________ _______________________ _______________________ _______________________ ____________  _  Depend1nciaa em ADs: ( Depend1nci ( ! higiene locomoção

(

! sim

! &est8rio

( (

! não ! alimentação

(

! tranfer1ncias

(

!

$tras: ______________________ _________________________________ _______________________ _______________________ ___________________  ________   _______________________  ____________ _______________________ _______________________ _______________________ _______________________ ____________  _ 

Aspecto Psicológico

Antes: ________________________________________________________________   _______________________  ____________ _______________________ _______________________ _______________________ _______________________ ____________  _  Atalmente:________________ Atalmente:_____ _______________________ _______________________ _______________________ _____________________  _________   _______________________  ____________ _______________________ _______________________ _______________________ _______________________ ____________  _ 

Aspecto óciocultural

Con&+&io social (amigos, tr tra%alho!: a%alho!: _____________________ _________________________________ ____________________  ________   _______________________  ____________ _______________________ _______________________ _______________________ _______________________ ____________  _   ___________________________________  _______________________ _______________________ _______________________ _______________________ ____________  _  9reas de interesse (ho%%, la6er!: ___________________________________________   ___________________________________  _______________________ _______________________ _______________________ _______________________ ____________  _   _______________________  ____________ _______________________ _______________________ _______________________ _______________________ ____________  _  otina e ati&idades atais: ___________ ______________________ _______________________ _______________________ _______________  ____   ___________________________________  _______________________ _______________________ _______________________ _______________________ ____________  _   _______________________  ____________ _______________________ _______________________ _______________________ _______________________ ____________  _   _______________________  ____________ _______________________ _______________________ _______________________ _______________________ ____________  _ 

&"servaç!es'  ____________  _______________________ _______________________ _______________________ _______________________ _____________  _ 

 

 ___________________________________  _______________________ _______________________ _______________________ _______________________ ____________  _   _______________________  ____________ _______________________ _______________________ _______________________ _______________________ ____________  _   _______________________  ____________ _______________________ _______________________ _______________________ _______________________ ____________  _   _______________________  ____________ _______________________ _______________________ _______________________ _______________________ ____________  _   _______________________  ____________ _______________________ _______________________ _______________________ _______________________ ____________  _   _______________________  ____________ _______________________ _______________________ _______________________ _______________________ ____________  _   _______________________  ____________ _______________________ _______________________ _______________________ _______________________ ____________  _   _______________________  ____________ _______________________ _______________________ _______________________ _______________________ ____________  _   ____________  _______________________ _______________________ _______________________ _______________________ _______________________ ____________  _   _______________________  ____________ _______________________ _______________________ _______________________ _______________________ ____________  _   _______________________  ____________ _______________________ _______________________ _______________________ _______________________ ____________  _   _______________________  ____________ _______________________ _______________________ _______________________ _______________________ ____________  _