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ANAMNESE PSICOLGICA

Identificao
Nome do filho(a) __________________________________________________
Sexo: ______________ Idade: _______ anos _______ meses Apelido: _______
Nascimento: ______________________ Nacionalidade: ___________________
Escolaridade: _______________ Srie: _________ Perodo ________________
Escola: __________________________________________________________
Endereo (da escola): ______________________________________________
2. Filiao:
Pai: _____________________________________________ Idade: __________
Profisso: ________________________ Nacionalidade: ___________________
Me: ____________________________________________ Idade __________
Profisso: ________________________ Nacionalidade: ___________________
Endereo: ________________________________________________________
Bairro: ____________________________ Fone Res.: _____________________
Religio: _________________________________________________________
Indicao do tratamento: ____________________________________________
Indicao do nome do profissional: ____________________________________
Informaes Complementares:
A me trabalha fora? ____ Turno: _____ com quem fica a criana?________
Outras pessoas que residem na casa:
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Motivo da consulta
-

Queixa:

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Histria de queixa (quando e em que circunstncia comeou, como se

desenvolveu):
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Tratamento(s) anterior(es):

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Antecedentes Pessoais:
a) Concepo:
A criana foi desejada? __________
Observaes: _____________________________________________________
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b) Gestao:
Como a me estava emocionalmente? __________________________________
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Teve complicaes orgnicas? Em que ms? ____________________________
Traumatismo? ____________________________________________________

c) Parto
Maternidade ______________________________________________________
Como foram s 24 horas anteriores (me) e s 24 horas posteriores (me e criana) no
parto?
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Condies do parto:

normal (

tempo __________

cesrea (
precoce

)
- quanto meses

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tamanho ________

peso _________

Observaes: _____________________________________________________
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d) Desenvolvimento:
1- Alimentao:
lactncia materna? ________________ (caso no) Por que? ________________
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Como aceitou alimentos slidos? _____________________________________
Quando nasceram os primeiros dentes? ________________________________
Tem problemas de alimentao atualmente? Quais? _______________________
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Qual a atitude da famlia? ___________________________________________
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Observaes: _____________________________________________________
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Sono:
Como foi o sono desde pequeno? _____________________________________
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Houve poca em que melhorou ou piorou? ________ Quando? _____________
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Atualmente, como o sono? _________________________________________
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Qual a atitude dos pais? ____________________________________________
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Observaes: _____________________________________________________
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Desenvolvimento motor:
Quando sustentou a cabea? ________________ Sentou? __________________

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Engatinhou? __________ Ficou em p? ______________ Andou? ___________
Dificuldades no desenvolvimento: tendncia a cair? ___________ a machucar-se?
______ golpeava-se? _______ Dificuldades em manipular objetos? _______
Outras? ___________ Dificuldades atuais: ____________________________
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Qual a atitude dos pais? _____________________________________________
Lateralidade: _____________________________________________________
Observaes: _____________________________________________________
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6. Controle de esfncteres:
a) Quando deixou as fraldas? ________________________________________
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b) Aprendizagem do uso de pinico? ___________________________________
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c) Como foi feito? (com facilidade, castigos)? ______________________

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Quem fez o controle? _____________ Com que idade? ____________________
Vesical diurno? __________________ anal diurno? ______________________
Vesical noturno? _________________ anal noturno? _____________________
Observaes: _____________________________________________________
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7. Linguagem:
Quando falou as primeiras palavras? ____________ Quais foram? ___________
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Problemas de fala? Quais? ___________________________________________
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Desde quando? ____________________________________________________
Qual a atitude dos pais? _____________________________________________
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Observaes: _____________________________________________________
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Sociabilidade:

Tem amigos? ________ Que idade? ___________ Como o relacionamento


com eles? ______________________________________________________
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Que tipo de brincadeiras prefere? ____________________________________
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Como se comporta com adultos? ____________________________________
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Qual a atitude familiar? ____________________________________________
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Observaes: ____________________________________________________
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Escolaridade:
Grau de Instruo: _____ Escola: __________________________________
Leitura: ( ) bem ( ) regular ( ) mau Escrita: ( ) bem ( ) regular ( ) mau
Dificuldade de aprendizagem: ____ disciplinas: _______________________
J foi reprovado: _____: Quantas vezes: _____ Atitude tomada: _________
Que escola(s) freqentou? ___________________________________________
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Com que idade ingressou?_______ Teve problemas em se adaptar escola?
Quais?
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Apresentou dificuldades atualmente, quando ao rendimento escolar? _________


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Qual o comportamento? ____________________________________________
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O que diz a professora? _____________________________________________
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Qual a atitude dos pais? _____________________________________________
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Observaes: _____________________________________________________
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Sexualidade:

Manifesta curiosidade sexual? __________ Que pergunta faz? _____________


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Qual a atitude dos pais?____________________________________________
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Teve orientao? Por parte de quem? _________________________________
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Masturba-se? _______ Brincadeiras sexuais com outras crianas? __________
Quais? _________________________________________________________
Qual a atitude dos pais? ___________________________________________

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Manipulao e tiques:

Usou chupeta? _______ at quando? __________ Chupava o dedo? ________


At quando? _________ Apresenta outras manipulaes? Quais? ___________
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Tiques? _________________________________________________________
Qual a atitude dos pais? ____________________________________________
Observaes: ____________________________________________________
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Formas de Reaes: (s ordens, s proibies, frustraes, relacionamento diante
estranhos, defende-se, etc.)
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Traos de Personalidade: (Tmida, inquieta, hiperativa, retrada, saliente, amvel, etc.)

Doenas:

Doenas infantis (quais e em que idade)? _______________________________


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Operaes (quais e em que idade)? ____________________________________
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Traumatismo, quedas (idade)? ________________________________________
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Desmaios, ausncias (idade) _________________________________________
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Tem alguma doena atualmente? ________ Qual? ________________________


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Est sendo tratado? ________________________________________________
Observaes: _____________________________________________________
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Antecedentes Familiares:
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Exame Psquico: ( circunstncia de atendimento, aparncia, psicomotricidade, humor,


pensamento, orientao, memria, vontade, rapport, etc.)
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Relato Espontneo:
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