ANAMNESE CASAL

IDENTIFICAÇÃO:
Nome:
Data de Nascimento: Idade:
Religião:
Endereço:
Profissão:
Telefone: E-mail:

IDENTIFICAÇÃO:
Nome:
Data de Nascimento: Idade:
Religião:
Endereço:
Profissão:
Telefone: E-mail:

MOTIVO DA CONSULTA E HISTORICO

QUEIXA PRINCIPAL:
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04- EVOLUÇÃO DA QUEIXA:

-Início da queixa:______________________________________________________________________
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- Súbita ou progressiva:_________________________________________________________________
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- Quais as mudanças que ocorreram/ o que afetou:____________________________________________

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- Sintomas:___________________________________________________________________________
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QUEIXAS SECUNDÁRIAS:
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HISTORIA DO CASAL- como se conheceram, como se apaixonaram, pontos negativos e pontos

positivos
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HISTÓRIA FAMILIAR:
-Composição Familiar:________________________________________________________________
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-Dinâmica Familiar:____________________________________________________________________
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-Eventos Significativos:________________________________________________________________
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HISTÓRIA SOCIAL:
- Vida Social:_________________________________________________________________________
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- Hábitos de lazer: _____________________________________________________________________
- Inserção em Grupos:__________________________________________________________________
- Rede de Apoio:______________________________________________________________________

CONSIDERAÇÕES FINAIS:
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Gisele Ribeiro Gomes Rodrigues

Psicóloga CRP08/22651