Anamnese Completa do Adulto

Nome:_______________________________________________________________________________
Idade:_____________ Sexo:_______________
Endereço:____________________________________________________________________________
Telefones para Contato:_________________________________________________________________
Bairro:____________________________ Cidade:__________________________________________
Religião:___________________________ Escolaridade:___________________________
Filhos (nome, idade e sexo)______________________________________________________________
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Profissão:_____________________________________________________________________________
Est.Civil:___________________
Cônjuge (nome, idade e profissão):________________________________________________________
Queixa principal:_______________________________________________________________________
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Possibilidade de horários:________________________________________________________________
Fez terapia anteriormente? (citar qual e quando)______________________________________________
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Sintomas apresentados:__________________________________________________________________
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Parte I – Diagnóstico
Transtornos psiquiátricos anteriores:_______________________________________________________
Transtornos psiquiátricos familiares:_______________________________________________________
Doenças Importantes que teve:____________________________________________________________
Medicação que está tomando:_____________________________________________________________
Medicação alternativa (chás, compostos, etc.)________________________________________________
Histórico da Queixa
Quando se iniciou:_____________________________________________________________________
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Eventos traumáticos de vida:_____________________________________________________________
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Eventos/fatores que precipitam ou agravam crises:____________________________________________
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Uso de drogas?________________________________________________________________________
Tentativa de suicídio?___________________________________________________________________
Focos de intervenção psicoterápica:________________________________________________________
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Parte II – Relacionamentos Importantes

Mãe:________________________________________________________________________________
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Pai:_________________________________________________________________________________
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Irmãos:______________________________________________________________________________
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Filhos:_______________________________________________________________________________
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Outros importantes:_____________________________________________________________________
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Observações sobre dinâmica familiar atual:__________________________________________________
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Parte III – Adolescência
Experiências afetivas
marcantes____________________________________________________________________________
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Experiências sexuais marcantes:___________________________________________________________
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Independência/ primeiros empregos:_______________________________________________________
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Círculo de amizades:____________________________________________________________________
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Parte IV – Vida Adulta

Relacionamento com parceiro:____________________________________________________________
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Vida Sexual Atual:_____________________________________________________________________
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Situação Financeira:____________________________________________________________________
Abortos espontâneos/provocados:_________________________________________________________
Apoio Social disponível:_________________________________________________________________
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Outros transtornos atuais (sono, alimentação, tiques,etc.):_______________________________________
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Principais lazeres, vida social:____________________________________________________________
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Parte V – Observação e Linguagem Não verbal do Paciente
Observações:__________________________________________________________________________
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