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

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

__________________________________________________________________________________ _____________________________________ Assinatura do profissional 4 .