Anamnese Completa do Adulto

Nome:__________________________________________________________
Idade:_____________ Sexo:_______________
Endereço:_______________________________________________________
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Telefones para Contato:____________________________________________
Bairro:____________________________
Cidade:___________________________
Religião:___________________________
Escolaridade:_______________________

Filhos (nome, idade e sexo)_________________________________________

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Profissão:_______________________________________________________

Est.Civil:___________________

Cônjuge (nome, idade e profissão):___________________________________

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Queixa principal:__________________________________________________
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Possibilidade de horários:___________________________________________
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 – Diagnóstico

Eixo I:__________________________________________________________

Eixo II:__________________________________________________________
Eixo III (doenças físicas):___________________________________________
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Eixo IV (estressores psicossociais):___________________________________

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Eixo V (funcionamento global):_______________________________________

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Conceituação Psicológica do Caso:___________________________________

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Transtornos psiquiátricos anteriores:__________________________________

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Transtornos psiquiátricos familiares:__________________________________

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Doenças Importantes que teve:______________________________________

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Medicação que está

tomando:_______________________________________________________
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Medicação alternativa (chás, compostos, etc.)___________________________

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

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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 (quais)?_____________________________________________

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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 – Infância

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

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Amamentação:___________________________________________________
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Treinamento de Higiene:____________________________________________
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Estressores na infância, crises:______________________________________

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Outros transtornos infantis (sono, alimentação, psicomotor, gagueira,

tiques,
sonambulismo, aprendizagem):______________________________________
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Outros comentários:_______________________________________________
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Parte IV – 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 V – Vida Adulta

Relacionamento com parceiro:_______________________________________

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Vida Sexual Atual:_________________________________________________

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Situação
Financeira:______________________________________________________
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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 VI – Observação e Linguagem Não verbal do Paciente

Observações:____________________________________________________
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Parte VII – Atendimentos Prestados

Profissional:_____________________________________________________

Encaminhamentos Feitos:__________________________________________
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Terapêutica Utilizada (prescrição de exercícios, leituras, relaxamento,

etc.):___________________________________________________________
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Destino do caso:

Alta ( )
Encaminhamento a outra instituição ( ) Qual
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Abandono ( )
Motivo___________________________________________________
Encaminhamento a outro profissional ( ) Quem
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Interrompido ( ) Por que___________________________________________

Melhoras
Obtidas:_________________________________________________________
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