Consultório de Psicologia e Centro de Estudos

ANAMNESE ADULTO

Nome: _______________________________________________________________________
Forma como gostaria de ser chamado(a): ___________________________________________
Data Nasc: __/__/____ Idade: ________________ Sexo:____________ Religião:
____________ RG: ___________________________________________
CPF:__________________________
Endereço: ____________________________________________________________________
Bairro: ___________________________________________ CEP:
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Tels: (resid.) __________________________________ (cel.) ___________________________
Naturalidade:_______________________________ Escolaridade: _______________________
Ocupação: ____________________________.
DADOS FAMILIARES:
Estado civil:
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Mora com quem?
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Nome do pai:
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Idade: ___________________ Profissão: __________________________ Vivo? ( ) sim ( )
não
Nome da mãe: _________________________________________________________________
Idade: ___________________ Profissão: __________________________ Vivo? ( ) sim ( )
não
Quantidade de irmãos: (Sexo masc.): ________________ (Sexo fem.):
_____________________

1. Queixa Inicial:
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2. Infância:
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3. Adolescência:
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4. Relação com os pais e outros familiares:
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5. Relações com amigos/apoio social

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6. Trabalho:
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7. Questões espirituais/religiosas
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8. Objetivos e aspirações
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9. Histórico de problemas de saúde:

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10. Histórico de problemas mentais na família:

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11. Acontecimentos importantes ou traumas na vida.

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12. Tentativas prévias de suicídio ou ideação/comportamento autodestrutivo

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13. Medicamentos:
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14. Qual sua expectativa em relação à psicoterapia?

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