CADASTRO
Nome: ___________________________________________________________________
Idade: _______Data nascimento: ____________ Escolaridade:_______________________
Naturalidade:_______________________________________________________________
Endereço residencial: ________________________________________________________
Telefone: ___________________________ Telefone: ______________________________
Telefone familiar e nome:______________________________________________________
Profissão: __________________________ Local Trabalho: __________________________
Estado civil: ________________________ Nome cônjuge: ___________________________
Composição Familiar:________________________________________________________
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Encaminhado por: __________________________________________________________
Uso SPA ( ) Sim ( )Não Sofreu Abuso ( ) sexual ( ) físico ( )verbal
Hospitalização psiquiátrica e/ ou atendimentos psicológicos e/ ou psiquiátricos ou
medicações anteriores:
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Medicação uso contínuo: _____________________________________________________
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Campo Grande - MS, ____ de ________________ de 2021
Rua Amazonas 427, Monte Castelo. Cel: (67) 98182 4293
E-mail: consultoriodoutorasilvana@[Link] - Campo Grande/MS
ANAMNESE
Qual o motivo de sua vinda aqui?
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Quando surgiram estas queixas?
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Houve algum fator agravante dos sintomas?
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Houve alguma melhora em algum momento? Qual seria a causa?
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Qual a atitude da família em relação aos problemas relatados?
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Outras queixas?
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Rua Amazonas 427, Monte Castelo. Cel: (67) 98182 4293
E-mail: consultoriodoutorasilvana@[Link] - Campo Grande/MS
História de vida
Gestação / Parto / DNPM / Enurese / Alfabetização / Puberdade/ Menarca / Sexarca
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Antecedentes Pessoais Patológicos:
Rua Amazonas 427, Monte Castelo. Cel: (67) 98182 4293
E-mail: consultoriodoutorasilvana@[Link] - Campo Grande/MS
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Antecedentes Familiares Patológicos:
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História Conjugal:
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Atividade Social, Lazer e Religião:
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Impressão do Caso:
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Hipótese Diagnóstica:
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Conduta:
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História de vida
Rua Amazonas 427, Monte Castelo. Cel: (67) 98182 4293
E-mail: consultoriodoutorasilvana@[Link] - Campo Grande/MS
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Rua Amazonas 427, Monte Castelo. Cel: (67) 98182 4293
E-mail: consultoriodoutorasilvana@[Link] - Campo Grande/MS