Você está na página 1de 7

BEM VIVER PSICOLOGIA CLÍNICA 2018

CNPJ: 24.474.328/0001-08
Walace Rodrigues – Psicó logo CRP 04/44639

Anamnese Completa Adulto


Nome:____________________________________________________________________
Idade:_____________ Sexo:_______________
CPF:____________________________ Identidade:_______________________________
Endereço:________________________________________________________________________
__________________________________________________________________
Telefones para Contato:______________________________________________________
Bairro:____________________________ Cidade:________________________________
Religião:___________________________ Escolaridade:___________________________
Filhos (nome, idade e sexo)___________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Profissão:_________________________________________________________________
Est.Civil:___________________
Cônjuge (nome, idade, profissão, escolaridade):__________________________________
_________________________________________________________________________
Queixa principal:___________________________________________________________
________________________________________________________________________________
__________________________________________________________________
Possibilidade de horários:____________________________________________________
Fez terapia anteriormente? (citar qual e quando)___________________________________
_________________________________________________________________________
Expectativas e objetivos do paciente:___________________________________________
________________________________________________________________________________
__________________________________________________________________
Sintomas apresentados:______________________________________________________
________________________________________________________________________________
__________________________________________________________________

Rua João da Silva Araújo, nº 05 Apto 101 – CEP: 35.300-238


Telefone: (33) 3322-3551 – Celular: (33) 98842-3003 WhatsApp
CARATINGA – MINAS GERAIS Página 1
BEM VIVER PSICOLOGIA CLÍNICA 2018
CNPJ: 24.474.328/0001-08
Walace Rodrigues – Psicó logo CRP 04/44639

Doenças físicas:____________________________________________________________
_________________________________________________________________________
Estressores psicossociais:_____________________________________________________
_________________________________________________________________________
Funcionamento global:_______________________________________________________

Conceituação Psicológica do Caso:_____________________________________________


________________________________________________________________________________
__________________________________________________________________

Transtornos psiquiátricos anteriores:____________________________________________

Transtornos psiquiátricos familiares:____________________________________________

Doenças Importantes que teve:________________________________________________

Medicação que está tomando:_________________________________________________


Medicação alternativa (chás, compostos, etc.)_____________________________________

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


________________________________________________________________________________
________________________________________________________________________________
___________________________________________________________

Histórico da Queixa
Quando se iniciou:__________________________________________________________
________________________________________________________________________________
__________________________________________________________________
Eventos traumáticos de vida:__________________________________________________

Rua João da Silva Araújo, nº 05 Apto 101 – CEP: 35.300-238


Telefone: (33) 3322-3551 – Celular: (33) 98842-3003 WhatsApp
CARATINGA – MINAS GERAIS Página 2
BEM VIVER PSICOLOGIA CLÍNICA 2018
CNPJ: 24.474.328/0001-08
Walace Rodrigues – Psicó logo CRP 04/44639

________________________________________________________________________________
__________________________________________________________________
Eventos/fatores que precipitam ou agravam crises:_________________________________
_________________________________________________________________________

Uso de drogas?_____________________________________________________________
Tentativa de suicídio?_______________________________________________________
Focos de intervenção psicoterápica:_____________________________________________
________________________________________________________________________________
________________________________________________________________________________
___________________________________________________________

Relacionamentos Importantes

Conjuje:__________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Mãe:____________________________________________________________________________
__________________________________________________________________
________________________________________________________________________________
__________________________________________________________________
Pai:_____________________________________________________________________________
__________________________________________________________________
________________________________________________________________________________
__________________________________________________________________
Irmãos:__________________________________________________________________________
__________________________________________________________________
_________________________________________________________________________

Rua João da Silva Araújo, nº 05 Apto 101 – CEP: 35.300-238


Telefone: (33) 3322-3551 – Celular: (33) 98842-3003 WhatsApp
CARATINGA – MINAS GERAIS Página 3
BEM VIVER PSICOLOGIA CLÍNICA 2018
CNPJ: 24.474.328/0001-08
Walace Rodrigues – Psicó logo CRP 04/44639

Filhos:__________________________________________________________________________
___________________________________________________________________
________________________________________________________________________________
__________________________________________________________________
Outros importantes:_________________________________________________________
________________________________________________________________________________
__________________________________________________________________

Observações sobre dinâmica familiar atual:______________________________________


________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
____________________________________________________

Infância

Gravidez (planejada ou não), parto, intercorrências obstétricas:_______________________


________________________________________________________________________________
__________________________________________________________________
Amamentação:____________________________________________________________________
__________________________________________________________________
Treinamento de Higiene:_____________________________________________________
________________________________________________________________________________
__________________________________________________________________
Estressores na infância, crises:_________________________________________________
________________________________________________________________________________
__________________________________________________________________
Outros transtornos infantis (sono, alimentação, psicomotor, gagueira, tiques, sonambulismo,
aprendizagem):________________________________________________

Rua João da Silva Araújo, nº 05 Apto 101 – CEP: 35.300-238


Telefone: (33) 3322-3551 – Celular: (33) 98842-3003 WhatsApp
CARATINGA – MINAS GERAIS Página 4
BEM VIVER PSICOLOGIA CLÍNICA 2018
CNPJ: 24.474.328/0001-08
Walace Rodrigues – Psicó logo CRP 04/44639

________________________________________________________________________________
__________________________________________________________________
Outros comentários:_________________________________________________________
________________________________________________________________________________
__________________________________________________________________

Adolescência

Experiências afetivas marcantes:_______________________________________________


________________________________________________________________________________
________________________________________________________________________________
___________________________________________________________
Experiências sexuais marcantes:_______________________________________________
________________________________________________________________________________
__________________________________________________________________
Independência/ primeiros empregos:____________________________________________
________________________________________________________________________________
__________________________________________________________________
Círculo de amizades:________________________________________________________
________________________________________________________________________________
__________________________________________________________________

Vida Adulta

Relacionamento com parceiro:_________________________________________________


________________________________________________________________________________
__________________________________________________________________
Vida Sexual Atual:__________________________________________________________

Rua João da Silva Araújo, nº 05 Apto 101 – CEP: 35.300-238


Telefone: (33) 3322-3551 – Celular: (33) 98842-3003 WhatsApp
CARATINGA – MINAS GERAIS Página 5
BEM VIVER PSICOLOGIA CLÍNICA 2018
CNPJ: 24.474.328/0001-08
Walace Rodrigues – Psicó logo CRP 04/44639

________________________________________________________________________________
__________________________________________________________________
Situação Financeira:_________________________________________________________
_________________________________________________________________________
Abortos espontâneos/provocados:______________________________________________

Apoio Social disponível:_____________________________________________________


_________________________________________________________________________
Outros transtornos atuais (sono, alimentação, tiques,etc.):___________________________
_________________________________________________________________________
Principais lazeres, vida social:_________________________________________________
________________________________________________________________________________
__________________________________________________________________

Observação e Linguagem Não verbal do Paciente

Observações:_____________________________________________________________________
________________________________________________________________________________
___________________________________________________________
________________________________________________________________________________
__________________________________________________________________

Atendimentos Prestados

Profissional:_______________________________________________________________

Encaminhamentos Feitos:____________________________________________________
________________________________________________________________________________
__________________________________________________________________
Terapêutica Utilizada (prescrição de exercícios, leituras, relaxamento, etc.):_____________

Rua João da Silva Araújo, nº 05 Apto 101 – CEP: 35.300-238


Telefone: (33) 3322-3551 – Celular: (33) 98842-3003 WhatsApp
CARATINGA – MINAS GERAIS Página 6
BEM VIVER PSICOLOGIA CLÍNICA 2018
CNPJ: 24.474.328/0001-08
Walace Rodrigues – Psicó logo CRP 04/44639

________________________________________________________________________________
________________________________________________________________________________
___________________________________________________________

Rua João da Silva Araújo, nº 05 Apto 101 – CEP: 35.300-238


Telefone: (33) 3322-3551 – Celular: (33) 98842-3003 WhatsApp
CARATINGA – MINAS GERAIS Página 7