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ANAMNESE PSICOLOGO

I - IDENTIFICAÇÃO

NOME: _______________________________ IDADE: ________ DATA: ____/____/____

Qual a sua droga de escolha __________________________________________________

Já teve internação psiquiátrica?

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Quantas internações você teve até hoje? _________________________________

Em média, quanto tempo duraram as internações? _____________________________

Há quanto tempo foi a última internação? ________________________

Qual seu grau de escolaridade? ___________________________________________

Qual sua profissão? ________________________________________

Estado civil: ( ) Casado ( ) Solteiro ( ) Viúvo ( ) Divorciado

II – ANTECEDENTES MÓRBIDOS PESSOAIS

Já Teve episódios de surto? ______________________________________________________

Já tentou suicídio? _______________________________________________________

FAMÍLIA

Infância:______________________________________________________________________
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Adolescência:__________________________________________________________________
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Como foi o seu relacionamento com a família? (Pai, Mãe, Irmão, Filhos, Esposa)

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PARECER PSICOLÓGICO

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