ANAMNESE ADOLESCENTE

1. DADOS PESSOAIS:
NOME:____________________________________________________________________________________________
ENDEREÇO:_______________________________________________________________________________________
CASAAPTº/BAIRRO/CEP/CIDADE:_____________________________________________________________________
TELEFONE RESIDENCIAL E CELULAR:( )______________________________________________________________
EMAIL:____________________________________________________________________________________________
DATA DE NASCIMENTO:_________________-_______ANOS - LOCAL
NASC.:___________________________________
ESCOLARIDADE:_______________________________ PROFISSÃO:________________________________________
RG:_________________________________________ CPF:_________________________________________________
NOME DA MÃE:______________________________________________________IDADE:________________________
PROFISSÃO:_______________________________ESCOLARIDADE:_________________________________________
NOME DO PAI:_______________________________________________________IDADE:______________
PROFISSÃO:_______________________________ESCOLARIDADE:_________________________________
DESCREVA DE FORMA RESUMIDA COMO FUNCIONA A ROTINA DA FAMÍLIA?
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2. DADOS ESCOLARES:
INSTITUIÇÃO DE ENSINO:___________________________________________________________________
REDE PÚBLICA OU PRIVADA?_________________ MÉDIA GERAL:___________________________________
OUTROS:________________________________________________________________________________

OMPTº PROBLEMA QUE MOTIVOU A PROCURA PELA PSICOLOGIA:_______________________________

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DIMENSÃO DO COMPTº PROBLEMA:
FREQUÊNCIA:____________________________________________________________________________
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INTENSIDADE:___________________________________________________________________________
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DURAÇÃO:______________________________________________________________________________
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CIRCUNSTÂNCIAS NAS QUAIS OCORRE:_______________________________________________________
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4. HISTÓRICO DO COMPTº PROBLEMA:
QUANDO INICIOU:________________________________________________________________________
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COMO INICIOU?__________________________________________________________________________
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COMO SE DESENVOLVEU ATÉ APRESENTAR-SE DE FORMA ATUAL?_________________________________
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O QUE OCORRE IMEDIATAMENTE ANTES E DEPOIS DA OCORRÊNCIA DO PROBLEMA?__________________
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HOUVE TRATAMENTO ANTERIOR PARA ESSE PROBLEMA?________________________________________
5. CONDIÇÕOES GERAIS DO PACIENTE:
DOENÇAS:_______________________________________________________________________________
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ALIMENTAÇÃO:___________________________________________________________________________
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INDEPENDÊNCIA/DEPENDÊNCIA:_____________________________________________________________
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6. OUTRAS OBSERVAÇÕES:
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