ANAMNESE

ROTEIRO DE ENTREVISTA PARA AVALIAÇÃO PSICOLÓGICA

01- DADOS DE IDENTIFICAÇÃO:

Nome:
Data de Nascimento: Idade:
Religião:
Curso: Centro: Período:
Matrícula: Protocolo:
Contato:
Encaminhado por:
ENCAMINHAMENTO:
PROFISSIONAL RESPONSÁVEL:

02- DADOS DE INDENTIFICAÇÃO DOS PAIS:

Nome Pai: Idade:
Profissão: Empresa:
Grau de instrução:
Nome Mãe: Idade:
Profissão: Empresa:
Grau de instrução:
Endereço:
Telefone: E-mail
Estado civil:

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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05- QUEIXAS SECUNDÁRIAS:
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06- HISTÓRIA CLÍNICA:

-Doença crônica: -
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-Uso de medicamentos. Quais:

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-Casos de internação:
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-Enfrentamento: _______________________________________________________________________
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-Sintomas físicos e/ou psicológicos:________________________________________________________
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- Psicoterapia/fono/fisio/neuro/psiquiatria:
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- Hábitos Alimentares:

Para crianças ou adolescentes:

- Condições de Nascimento:

- Desenvolvimento Neuropsicomotor:
- Doenças infantis:
- Casos de convulsões,epilepsia,desmaios etc: -

07- HISTÓRIA FAMILIAR:

Composição Familiar: (genotograma)

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

08- HISTÓRIA SOCIAL:

- Vida Social:
- Hábitos de lazer:
- Inserção em Grupos:
- Rede de Apoio:

09- DADOS ESCOLARES:

- Casos de reprovação:

- Áreas de dificuldade:
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- Hábitos de Estudo:.

10- CONSIDERAÇÕES FINAIS::

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11- SUGESTÃO DE ENCAMINHAMENTO:

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Assinatura do profissional