Anamnese Completa do Adulto

Nome:____________________________________________________________________
Idade:_____________ Sexo:_______________
Endereo:_________________________________________________________________
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Telefones para Contato:______________________________________________________
Bairro:____________________________ Cidade:________________________________
Religio:___________________________ Escolaridade:___________________________
Filhos (nome, idade e sexo)___________________________________________________
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Profisso:_________________________________________________________________
Est.Civil:___________________
Cnjuge (nome, idade e profisso):_____________________________________________
Queixa principal:___________________________________________________________
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Possibilidade de horrios:____________________________________________________
Fez terapia anteriormente? (citar qual e quando)___________________________________
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Expectativas e objetivos do paciente:___________________________________________
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Sintomas apresentados:______________________________________________________
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Parte I Diagnstico

Eixo I:____________________________________________________________________
Eixo II:___________________________________________________________________
Eixo III (doenas fsicas):____________________________________________________
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Eixo IV (estressores psicossociais):_____________________________________________
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Eixo V (funcionamento global):________________________________________________

Conceituao Psicolgica do Caso:_____________________________________________

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Transtornos psiquitricos anteriores:____________________________________________

Transtornos psiquitricos familiares:____________________________________________

Doenas Importantes que teve:________________________________________________

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Medicao que est tomando:_________________________________________________
Medicao alternativa (chs, compostos, etc.)_____________________________________

Aplicao de Testes? Se sim, qual e resultado:____________________________________

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Histrico da Queixa
Quando se iniciou:__________________________________________________________
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Eventos traumticos de vida:__________________________________________________
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Eventos/fatores que precipitam ou agravam crises:_________________________________
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Uso de drogas?_____________________________________________________________
Tentativa de suicdio?_______________________________________________________
Focos de interveno psicoterpica:_____________________________________________
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Parte II Relacionamentos Importantes

Me:_____________________________________________________________________
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Pai:______________________________________________________________________
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Irmos:___________________________________________________________________
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Filhos:____________________________________________________________________
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Outros importantes:_________________________________________________________
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Observaes sobre dinmica familiar atual:______________________________________

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Parte III Infncia

Gravidez (planejada ou no), parto, intercorrncias obsttricas:_______________________

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Amamentao:_____________________________________________________________
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Treinamento de Higiene:_____________________________________________________
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Estressores na infncia, crises:_________________________________________________
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Outros transtornos infantis (sono, alimentao, psicomotor, gagueira, tiques,
sonambulismo, aprendizagem):________________________________________________
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Outros comentrios:_________________________________________________________
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Parte IV Adolescncia

Experincias afetivas marcantes:_______________________________________________

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Experincias sexuais marcantes:_______________________________________________
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Independncia/ primeiros empregos:____________________________________________
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Crculo de amizades:________________________________________________________
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Parte V Vida Adulta

Relacionamento com parceiro:_________________________________________________

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Vida Sexual Atual:__________________________________________________________
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Situao Financeira:_________________________________________________________
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Abortos espontneos/provocados:______________________________________________
Apoio Social disponvel:_____________________________________________________
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Outros transtornos atuais (sono, alimentao, tiques,etc.):___________________________
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Principais lazeres, vida social:_________________________________________________
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Parte VI Observao e Linguagem No verbal do Paciente

Observaes:______________________________________________________________
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Parte VII Atendimentos Prestados

Profissional:_______________________________________________________________

Encaminhamentos Feitos:____________________________________________________
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Teraputica Utilizada (prescrio de exerccios, leituras, relaxamento, etc.):_____________
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Data: __/__/__ Tema:______________________________________________________

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Destino do caso:
Alta ( )
Encaminhamento a outra instituio ( ) Qual ________________________________
Abandono ( ) Motivo___________________________________________________
Encaminhamento a outro profissional ( ) Quem ________________________________
Interrompido ( ) Por que__________________________________________________

Melhoras Obtidas:__________________________________________________________

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Outras Observaes Importantes:______________________________________________

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