Ficha Anamnese – Cocoon Instituto Holístico - Terapeuta Elba Valverde

Anamnese Completa

Nome:_____________________________________________________________________
Idade:_____________ Sexo:_______________
Endereço:___________________________________________________________________
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Telefones para Contato:_______________________________________________________
Bairro:____________________________ Cidade:__________________________________
Religião:___________________________ Escolaridade:____________________________
Filhos (nome, idade e sexo)___________________________________________________
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Profissão:_________________________________________________________________
Est.Civil:___________________
Cônjuge (nome, idade e profissão):_____________________________________________

Queixa principal:____________________________________________________________
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Possibilidade de horários:____________________________________________________

Fez terapia anteriormente? (citar qual e quando)___________________________________

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Expectativas e objetivos do paciente:____________________________________________

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Ficha Anamnese – Cocoon Instituto Holístico - Terapeuta Elba Valverde

Sintomas apresentados:______________________________________________________
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Parte I – Diagnóstico
Eixo I:____________________________________________________________________
Eixo II:___________________________________________________________________
Eixo III (doenças físicas):____________________________________________________
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Eixo IV (estressores psicossociais):_____________________________________________
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Eixo V (funcionamento global):________________________________________________

Conceituação Psicológica do Caso:_____________________________________________

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Transtornos psiquiátricos anteriores:____________________________________________
Transtornos psiquiátricos familiares:____________________________________________
Doenças Importantes que teve:________________________________________________
Medicação que está tomando:_________________________________________________
Medicação alternativa (chás, compostos, etc.)_____________________________________
Aplicação de Testes? Se sim, qual e resultado:____________________________________
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Ficha Anamnese – Cocoon Instituto Holístico - Terapeuta Elba Valverde

Histórico da Queixa
Quando se iniciou:__________________________________________________________
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Eventos traumáticos de vida:__________________________________________________
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Eventos/fatores que precipitam ou agravam crises:_________________________________

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Uso de drogas?_____________________________________________________________
Tentativa de suicídio?_______________________________________________________
Focos de intervenção psicoterápica:_____________________________________________
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Parte II – Relacionamentos Importantes

Mãe:_______________________________________________________________________
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Pai:________________________________________________________________________
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Irmãos:_____________________________________________________________________
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Filhos:_____________________________________________________________________
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Ficha Anamnese – Cocoon Instituto Holístico - Terapeuta Elba Valverde

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Outros importantes:__________________________________________________________
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Observações sobre dinâmica familiar atual:_______________________________________
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Parte III – Infância

Gravidez (planejada ou não), parto, intercorrências obstétricas:_______________________
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Amamentação:_______________________________________________________________
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Estressores na infância, crises:_________________________________________________
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Outros transtornos infantis (sono, alimentação, psicomotor, gagueira, tiques, sonambulismo,
aprendizagem):______________________________________________________________
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Outros comentários:__________________________________________________________
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Parte IV – Adolescência
Ficha Anamnese – Cocoon Instituto Holístico - Terapeuta Elba Valverde

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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Parte V – Vida Adulta

Relacionamento com parceiro:_________________________________________________
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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.):___________________________
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Principais lazeres, vida social:_________________________________________________
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Ficha Anamnese – Cocoon Instituto Holístico - Terapeuta Elba Valverde

Parte VI – Observação e Linguagem Não verbal do Paciente

Observações:________________________________________________________________
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Parte VII – Atendimentos Prestados
Profissional:_______________________________________________________________
Encaminhamentos Feitos:____________________________________________________
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Terapêutica Utilizada (prescrição de exercícios, leituras, relaxamento, etc.):_____________
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Data: __/__/__ Tema:______________________________________________________

Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________

Destino do caso:
Alta ( )
Encaminhamento a outra instituição ( ) Qual ________________________________
Abandono ( ) Motivo___________________________________________________
Encaminhamento a outro profissional ( ) Quem ________________________________
Interrompido ( ) Por que__________________________________________________
Melhoras Obtidas:__________________________________________________________
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Ficha Anamnese – Cocoon Instituto Holístico - Terapeuta Elba Valverde

Outras Observações Importantes:_______________________________________________

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Terapia(s) Indicada(s):

Aromaterapia ( )
PNL ( )
Florais de Bach ( )
Constelação Familiar Sistêmica ( )
Terapia do Sagrado Feminino ( )
Regressão ( )
Hipnose ( )
Ficha Anamnese – Cocoon Instituto Holístico - Terapeuta Elba Valverde