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ROTEIRO DE ENTREVISTA PARA AVALIAO PSICOLGICA

DADOS DE IDENTIFICAO
NOME SOCIAL:
NOME:
DATA DE NASCIMENTO IDADE:
ESTADO CIVIL: RELIGIO
ORIENTAO SEXUAL: IDENTIDADE DE GNERO:
AMBULATRIO:

COMO FOI O ENFRENTAMENTO EM RELAO AO DIAGNSTICO?

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O QUE MUDOU DESDE A DESCOBERTA DA DOENA/VIRUS ? HOUVE ALGUMA ALTERAO

FISICA OU PSICOLOGIA?
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VOC SE SENTE CANSADO COM FRENQUENCIA ?

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COMO VOC CONSIDERA A QUALIDADE DE SEU SONO?

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VOC FAZ USO DE ALGUM MEDICAMENTO PARA DORMIR?

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VOC TEM DIFICULDADE PARA SE CONCENTRAR ?
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COM QUE FRENQUENCIA UMA DOR FISICA LHE IMPEDE DE FAZER ALGO QUE GOSTA?
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VOC CAPAZ DE ACEITAR SUA APARNCIA FISICA?

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COMO SUA RELAO COM SUA FAMILIA?

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COMO VOC AVALIA SUA VIDA SEXUAL ATUALMENTE?

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COMO VOC AVALIA SUA CAPACIDADE PARA O TRABALHO?

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QUANDO VOC NO ESTA TRABALHANDO E/OU EM CASA OQUE GOSTA DE FAZER?

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VOC VAI COM QUE FRENQUENCIA AO PSICOLOGO/PSIQUIATRA/FONO/NUTRI.?

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COM QUE FREQUNCIA VOC VOC TEM SENTIMENTOS ANGUSTIANTES, ANSIEDADE, DESESPERO,
DEPRESSO, OU ALTERAES DE HUMOR? QUANDO OCORRE?
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EVENTOS SIGNIFICATIVOS:
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SUGESTO DE ENCAMINHAMENTO:

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ASS. DO PROFESSIONAL