Inara Rodrigues – Psicó loga CRP 05/67922

Anamnese Psicológica Adulto

Nome: ____________________________________________________________________
Idade: _____________ Sexo: _______________
CPF: ____________________________ Identidade: _______________________________
Endereço:
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Telefones para Contato: ______________________________________________________
Bairro: ____________________________ Cidade: ________________________________
Religião: ___________________________ Escolaridade: ___________________________
Profissão: _________________________________________________________________
Estado Civil: _____________________________________

Queixa principal: ___________________________________________________________

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Fez terapia anteriormente? (Citar qual e quando) ___________________________________
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Expectativas e objetivos do paciente: ___________________________________________
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Sintomas apresentados: ______________________________________________________
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Doenças físicas: ____________________________________________________________
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Estressores psicossociais: _____________________________________________________
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Transtornos psiquiátricos anteriores: ____________________________________________

Transtornos psiquiátricos familiares: ____________________________________________

Doenças Importantes que teve: ________________________________________________

Medicação que está tomando: _________________________________________________

Histórico da Queixa
 Inara Rodrigues – Psicó loga CRP 05/67922

Quando se iniciou: __________________________________________________________

Eventos traumáticos de vida: __________________________________________________
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Uso de drogas? _____________________________________________________________
Tentativa de suicídio? _______________________________________________________

Relacionamentos Importantes
Cônjuge: __________________________________________________________________
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Mãe:
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Pai:
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Irmãos:
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Filhos:
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Outros importantes: _________________________________________________________
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Observações sobre dinâmica familiar atual: ______________________________________

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Infância

Gravidez (planejada ou não), parto, intercorrências obstétricas: _______________________

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 Inara Rodrigues – Psicó loga CRP 05/67922

Amamentação:
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Treinamento de Higiene: _____________________________________________________
Estressores na infância, crises: _________________________________________________
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Outros transtornos infantis (sono, alimentação, psicomotor, gagueira, tiques, sonambulismo,
aprendizagem): ________________________________________________
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Adolescência

Experiências afetivas marcantes: _______________________________________________

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Experiências sexuais marcantes: _______________________________________________
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Independência/ primeiros empregos: ____________________________________________
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Círculo de amizades: ________________________________________________________
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Vida Adulta

Relacionamentos importantes: _________________________________________________

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Vida Sexual Atual: __________________________________________________________
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Situação Financeira: _________________________________________________________
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Abortos espontâneos/provocados: ______________________________________________

Apoio Social disponível: _____________________________________________________

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Outros transtornos atuais (sono, alimentação, tiques,etc.):___________________________
 Inara Rodrigues – Psicó loga CRP 05/67922

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Principais lazeres, vida social: _________________________________________________
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Observação e Linguagem Não verbal do Paciente

Observações:_____________________________________________________________________
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Atendimentos Prestados

Profissional: _______________________________________________________________

Encaminhamentos Feitos: ____________________________________________________

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Terapêutica Utilizada (prescrição de exercícios, leituras, relaxamento, etc.): _____________

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