AC Clínica Psicológica

CRP: 06/51344

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Anamnese Completa Adulto
Nome:_____________________________________________________________________
Idade/Nasc:_____________ Sexo:_______________
CPF:___________________________Identidade:__________________________________
Endereço:__________________________________________________________________
Telefones/Emergência:_______________________________________________________
Bairro:__________________________Cidade:____________________________________
Religião:__________________________Escolaridade:______________________________
Filhos (nome, idade e sexo) ___________________________________________________
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Profissão:______________________________________Est.Civil:_____________________
Cônjuge (nome, idade, profissão, escolaridade):___________________________________
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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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Doenças físicas:_____________________________________________________________
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Estressores psicossociais:_____________________________________________________
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Funcionamento global:_______________________________________________________

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 AC Clínica Psicológica
CRP: 06/51344

Conceituação Psicológica do Caso:______________________________________________

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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:_____________________________________
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Histórico da Queixa
Queixa principal:____________________________________________________________
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Quando se iniciou:___________________________________________________________
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Eventos traumáticos de vida:___________________________________________________
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 AC Clínica Psicológica
CRP: 06/51344

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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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Relacionamentos Importantes
Conjuje:___________________________________________________________________
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Mãe:______________________________________________________________________
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Pai:_______________________________________________________________________
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Irmãos:____________________________________________________________________
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 AC Clínica Psicológica
CRP: 06/51344

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Filhos:_____________________________________________________________________
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Outros importantes:_________________________________________________________
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Observações sobre dinâmica familiar atual:______________________________________
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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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 AC Clínica Psicológica
CRP: 06/51344

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Outros transtornos infantis (sono, alimentação, psicomotor, gagueira, tiques,
sonambulismo, aprendizagem):________________________________________________
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Adolescência
Experiências afetivas marcantes:_______________________________________________
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Experiências sexuais marcantes:________________________________________________
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Experiências/traumas marcantes:_______________________________________________
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Independência/ primeiros empregos:____________________________________________
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Círculo de amizades:_________________________________________________________

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 AC Clínica Psicológica
CRP: 06/51344

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Vida Adulta
Relacionamento com parceiro:_________________________________________________
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Experiências afetivas marcantes:_______________________________________________
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Vida Sexual Atual:____________________________________________________________
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Trabalho:__________________________________________________________________
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Experiências/traumas marcantes:_______________________________________________
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Abortos espontâneos/provocados:______________________________________________

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 AC Clínica Psicológica
CRP: 06/51344

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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Observação e Linguagem Não verbais do Paciente
Observações:_______________________________________________________________
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Atendimentos Prestados
Profissional:_______________________________________________________________
Encaminhamentos Feitos:_____________________________________________________
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Terapêutica Utilizada (prescrição de exercícios, leituras, relaxamento, etc.):_____________
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