ANAMNESE

ROTEIRO DE ENTREVISTA PARA AVALIAÇÃO PSICOLÓGICA

01- DADOS DE IDENTIFICAÇÃO:
Nome:
Data de Nascimento:
Religião:
Curso: Centro:
Período:
Matrícula:
Contato:
Encaminhado por:
ENCAMINHAMENTO:
PROFISSIONAL RESPONSÁVEL:

Idade:
Protocolo:

02- DADOS DE INDENTIFICAÇÃO DOS PAIS:
Nome Pai:
Profissão:
Grau de instrução:
Nome Mãe:
Profissão:
Grau de instrução:
Endereço:
Telefone:
Estado civil:

Idade:
Empresa:
Idade:
Empresa:
E-mail

03- QUEIXA PRINCIPAL:

04- EVOLUÇÃO DA QUEIXA:
-Início da queixa:______________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
- Súbita ou progressiva:_________________________________________________________________
____________________________________________________________________________________
- Quais as mudanças que ocorreram/ o que afetou:____________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
- Sintomas:___________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
1

HISTÓRIA CLÍNICA: -Doença crônica: _____________________________________________________________________________________ -Uso de medicamentos.Condições de Nascimento: .HISTÓRIA FAMILIAR: Composição Familiar: (genotograma) 2 .05.epilepsia.QUEIXAS SECUNDÁRIAS: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 06.desmaios etc: - 07.Desenvolvimento Neuropsicomotor: .Hábitos Alimentares: Para crianças ou adolescentes: .Psicoterapia/fono/fisio/neuro/psiquiatria: _________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ . Quais: _____________________________________________________________________________________ -Casos de internação: _____________________________________________________________________________________ -Enfrentamento: _______________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ -Sintomas físicos e/ou psicológicos:________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ .Casos de convulsões.Doenças infantis: .

Hábitos de lazer: .SUGESTÃO DE ENCAMINHAMENTO: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 3 .Vida Social: .Eventos Significativos:________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ -Rede de Apoio: 08.CONSIDERAÇÕES FINAIS:: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 11.Casos de reprovação: .Áreas de dificuldade: _____________________________________________________________________________________ .HISTÓRIA SOCIAL: . 10.Hábitos de Estudo:.Inserção em Grupos: .-Dinâmica Familiar:____________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ .Rede de Apoio: 09.DADOS ESCOLARES: .

__________________________________________________________________________________ _____________________________________ Assinatura do profissional 4 .

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