PSICÓLOGA | CRP-21/04564

Ficha de Anamnese Adolescente/Adulto

1. Dados sobre o paciente

Identificação:
Nome:______________________________________________________________________
Data de Nascimento: ___ /___ /_____ Idade: _______ Sexo: ______________
CPF: _______________________ RG: _______________
Naturalidade: ______________________ Estado civil: _______________________
Escolaridade: ______________________ Profissão: _________________________
Endereço residencial:__________________________________________________________
___________________________________________________________________________
Religião: _______________________ Praticante? ________________________
Tel. Celular: ____________________ E-mail: ___________________________

Dados sobre a família:

Cônjuge: ___________________________________________________________________
Naturalidade:____________________ Profissão: __________________________
Escolaridade: _______________________________________________________________
Filhos (nome, sexo / idade):_____________________________________________________
___________________________________________________________________________

Nome do Pai: ________________________________________________________________

Idade: __________________ Profissão: __________________________
Naturalidade:________________________ Escolaridade:_________________________

Nome da Mãe: _______________________________________________________________

Idade:__________________ Profissão: __________________________
Naturalidade:________________________ Escolaridade:__________________________

Irmãos:_____________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Condições sócio-econômicos:
Renda famíliar
( ) Até 1 salário mínimo ( ) De 1 a 2 salár. mínimos ( ) De 2 a 3 salár. mínimos
( ) De 3 a 5 salár. mínimos ( ) De 5 a 10 salár. mínimos ( ) De 10 a 20 salár. mínimos
( ) Mais de 20 salár. Mínimos

Quantas pessoas trabalham na família? ____________________________________________

Quais?______________________________________________________________________
Nº de dependentes: ___________________________________________________________

(89) 9 9455-1961
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PSICÓLOGA | CRP-21/04564

A família reside em:

( ) Casa ( ) Apartamento ( ) Cedido(a) ( ) Próprio(a)

( ) Quitado(a) ( ) Outro(a) ( ) Alugado(a) ( ) Financiado(a)

Observações:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Consulta a psicólogo anteriormente? ( ) Sim ( ) Não

Consulta a psiquiatra anteriormente?
- Ambulatório: ( ) Sim ( ) Não
- Internamento: ( ) Sim ( ) Não

Encaminhado por:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

2. Motivo da procura ao serviço de psicologia (queixa principal e secundária)

tratamentos anteriores, farmacologia.
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3. Histórico das dificuldades relatadas (desde quando apresenta a queixa; correlação

com fatos da vida, etc).
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

(89) 9 9455-1961
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PSICÓLOGA | CRP-21/04564

4. Expectativa quanto aos atendimentos:

___________________________________________________________________________
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5. Dinâmica familiar (relação com pais, avós, bisavós, irmãos):

___________________________________________________________________________
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___________________________________________________________________________
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6. Dinâmica do relacionamento social e lazer (trabalho, lazer, religião, amigos, colegas):

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
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7. Dinâmica das áreas escolar e profissional:

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
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___________________________________________________________________________

8. Familiar (histórico geral, estados de saúde repetitivos, tratamentos, etc):

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

(89) 9 9455-1961
@psi.isadoraac
isadoraaraujo.psi@outlook.com Psicóloga | CRP-21/04564
PSICÓLOGA | CRP-21/04564

9. Aspectos significativos percebidos durante as entrevistas.

- Postura Geral - Cuidados Pessoais E Com A Aparência
- Fluência Verbal - Organização Cognitiva (Ideias/Pensamento)
- Tiques, Hábitos E Manipulações
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10. Parecer diagnóstico – sintomatologia relatada:

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
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___________________________________________________________________________

11. Orientação terapêutica (encaminhamentos):

___________________________________________________________________________
___________________________________________________________________________

12. Sintese da consulta:

___________________________________________________________________________
___________________________________________________________________________
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São Francisco de Assis do Piauí – PI, ____ de ___________ de ______

Psicóloga
_____________________________________

(89) 9 9455-1961
@psi.isadoraac
isadoraaraujo.psi@outlook.com Psicóloga | CRP-21/04564