Escolar Documentos
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ANAMNESE DE ACOLHIMENTO
Nome_____________________________________________________________________________
Idade______ Data de nascimento: ____/ ____ / ____ Escolaridade:___________________________
Estado civil __________________ Filhos____________ Carto SUS___________________________
U.S de Referncia:______________________________ Profisso_____________________________
Trabalha atualmente: ( ) sim ( ) no Recebe algum benefcio (Previdencirio ou Assistencial)?
( ) sim ( ) no
Qual: ( )BPC ( ) Auxilio Doena ( ) Aposentadoria ( ) Penso por morte OBS: (Prxima Percia)
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Alguma pendncia judicial ou ocorrncia policial? __________________________________________
Qual o motivo da busca pelo CAPS?_____________________________________________________
J freqentou algum CAPS? ( )sim ( ) no Qual? ______________________________________
Histrico de Uso / Abuso de SPA : 1) substncias 2) quantidade 3) tempo de uso 4) maior tempo
abstmio:__________________________________________________________________________
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Histrico de internamentos / tratamentos : ( )Hospital Psiquitrico ( )Hospital - Dia ( ) CAPS ( )
Ambulatrio ( )C.T ( ) Clnicas Outros:_________________________________________________
Tempo mdio dos tratamentos:__________________________ Tipo de Alta:____________________
Apresenta Co-morbidades ? (Histrico de tratamentos anteriores)______________________________
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exames
laboratoriais
recentemente
(data
quais
os
exames
realizados)?
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Histrico Familiar (Uso, Abuso, Dependncia). Grau de parentesco e tipo de SPA de
abuso:____________________________________________________________________________
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Qual sua rotina diria?
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OBS:_____________________________________________________________________________
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Regime de tratamento:____________________________________________________________
Data: _____ /_____ / ______ - Profissional responsvel: _________________________________