Consulta Psicológica Individual

ANAMNESE

(Adulto)

Data: ____/____/____

IDENTIFICAÇÃO

Nome: _________________________________________________________________
Data de Nascimento: ____/____/____
Sexo: _______________
Naturalidade: ___________________
Estado Civil: ________________
Profissão: ________________________
Residência: _______________________
Telefone: ______________________
Observações:
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Filiação

Nome: _________________________________________________________________
Data de Nascimento: ____/____/____
Sexo: _______________
Naturalidade: ___________________
Estado Civil: ________________
Profissão: ________________________
Residência: _______________________

Nome: _________________________________________________________________
Data de Nascimento: ____/____/____
Sexo: _______________
Naturalidade: ___________________
Estado Civil: ________________
Profissão: ________________________
Residência: _______________________

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Fratria

Habilitações
Nome Idade Sexo Estado civil Profissão
Literárias

Habitação
Zona de Residência (Rural, Urbana, Mista, Outra): __________________________________
Tipo de Habitação: ___________________________________________________________
Observações:
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Encaminhamento

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Motivo
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GENOGRAMA

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 INTERACÇÃO FAMILIAR

Relação Pai/ Cliente (como o cliente descreve o pai: como era no passado e como é actualmente a
relação com o pai):
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Relação Mãe/ Cliente (como o cliente descreve a mãe: como era no passado e como é
actualmente a relação com a mãe):
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Relação Irmão (s)/ Cliente (como era no passado e como é actualmente a relação com o (s) irmão
(s):
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História Educacional

Nível Educacional: _____________________________________________________________

Aspectos mais significativos da Educação Infantil:
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Aspectos mais significativos da Educação Primária:
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Aspectos mais significativos da Educação Secundária:
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Aspectos mais significativos da Educação Superior:
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Principais Opções Vocacionais e qual a sua razão:
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Observações:
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 HISTÓRIA OCUPACIONAL

Profissão Actual: __________________________________________________________

Principais tarefas e responsabilidades profissionais actuais:
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Grau de satisfação com o trabalho:
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Principais trabalhos que desempenhou no passado e qual o grau de satisfação:
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Relação com os colegas de trabalho:
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Observações:
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HISTÓRIA CONJUGAL

Número de casamentos ou relações significativas:

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História e características de relações significativas anteriores:
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Nome do marido/ companheiro:
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Idade: _______
Profissão: ______________________________________________________
Como o cliente descreve o marido/ companheiro:
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Relação na passado e actualmente com o marido/ companheiro:
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N.º de Filhos: _______

Nome Idade Sexo Estado Civil Profissão Habilitações

Literárias

Relação Filhos/ Cliente:

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HISTÓRIA CLÍNICA

Doenças Significativas:
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Estado de Saúde Actual:
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Padrão de sono:
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Padrão de Alimentação e Bebida:
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Padrão de Actividade Física:
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Antecedentes Familiares:
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Observações:
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 INTERNAMENTO

Idade Motivo Duração Tratamento

Outros Dados

Expectativas em Relação à consulta Psicológica:

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Contacto anterior com Psicólogo/ Psiquiatra:
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Nome do Médico de Família: __________________________________________
Dificuldade e Grau de satisfação com a sua vida Sexual:
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Ocupação dos tempos livres e nível de satisfação derivado:
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Principais contextos sociais da sua vida:
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Relação com pessoas significativas/ Cliente:
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Observações:
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COMUNICAÇÃO NÃO VERBAL

Aparência Física

Vestuário:
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Estilo:
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Penteado:
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Outros:
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Movimentos

Gesticulação:
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Tiques:
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Manipulação:
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Outros:
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Postura

Relaxado: __________ Tenso: _________ Nervoso (a): _________ Agitado (a): ___________
Distante do Psicólogo: _________________ Próximo do Psicólogo: __________________

Contacto Ocular

Constante: __________ Esquino: _________ Ausente: ________

Expressão Facial

Sorrisos: __________ Caretas: _________ Serenidade: ________ Choro: ________

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Estado Emocional

Lágrimas: ______________ Olhos Húmidos: _____________ Rubor: ____________

Sudação: _____________ Voz Trémula: ______________
Gargalhadas sem contexto: ________________
Engolir saliva frequentemente: __________________

Características da Linguagem

Tom de Voz:
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Velocidade:
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Claridade:
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Omissões:
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Mudança de Temas:
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Observações:
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 Notas
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 Programa das sessões

Objectivos Terapêuticos:
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Sessão 1 – Sumário ___/___/___

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Sessão 2 – Sumário ___/___/___

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Sessão 3 – Sumário ___/___/___

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Sessão 4 – Sumário ___/___/___

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Sessão 5 – Sumário ___/___/___

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Sessão 6 – Sumário ___/___/___
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Sessão 7 – Sumário ___/___/___

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Sessão 8 – Sumário ___/___/___

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Sessão 9 – Sumário ___/___/___

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Sessão 10 – Sumário ___/___/___

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Sessão 11 – Sumário ___/___/___

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