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ANAMNESE

ROTEIRO DE ENTREVISTA PARA AVALIAO PSICOLGICA

01- DADOS DE IDENTIFICAO:


Nome:
Data de Nascimento:
Religio:
Curso: Centro:
Perodo:
Matrcula:
Contato:
Encaminhado por:
ENCAMINHAMENTO:
PROFISSIONAL RESPONSVEL:

Idade:
Protocolo:

02- DADOS DE INDENTIFICAO DOS PAIS:


Nome Pai:
Profisso:
Grau de instruo:
Nome Me:
Profisso:
Grau de instruo:
Endereo:
Telefone:
Estado civil:

Idade:
Empresa:
Idade:
Empresa:
E-mail

03- QUEIXA PRINCIPAL:

04- EVOLUO DA QUEIXA:


-Incio da queixa:______________________________________________________________________
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- Sbita ou progressiva:_________________________________________________________________
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- Quais as mudanas que ocorreram/ o que afetou:____________________________________________
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- Sintomas:___________________________________________________________________________
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05- QUEIXAS SECUNDRIAS:


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06- HISTRIA CLNICA:


-Doena crnica: _____________________________________________________________________________________
-Uso de medicamentos. Quais:
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-Casos de internao:
_____________________________________________________________________________________
-Enfrentamento: _______________________________________________________________________
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-Sintomas fsicos e/ou psicolgicos:________________________________________________________
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- Psicoterapia/fono/fisio/neuro/psiquiatria:
_________________________________________________________________________
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- Hbitos Alimentares:
Para crianas ou adolescentes:
- Condies de Nascimento:
- Desenvolvimento Neuropsicomotor:
- Doenas infantis:
- Casos de convulses,epilepsia,desmaios etc: -

07- HISTRIA FAMILIAR:


Composio Familiar: (genotograma)

-Dinmica Familiar:____________________________________________________________________
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- Eventos Significativos:________________________________________________________________
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-Rede de Apoio:

08- HISTRIA SOCIAL:


- Vida Social:
- Hbitos de lazer:
- Insero em Grupos:
- Rede de Apoio:

09- DADOS ESCOLARES:


- Casos de reprovao:
- reas de dificuldade:
_____________________________________________________________________________________
- Hbitos de Estudo:.

10- CONSIDERAES FINAIS::


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11- SUGESTO DE ENCAMINHAMENTO:


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Assinatura do profissional