ANAMNESE

R O T E I R O D E E N T R E V I S TA P S I C O L ÓG I C A

01- DADOS DE IDENTIFICAÇÃO:

Nome (Registro ou Social):

Data de Nascimento: Idade:

Endereço:

Com quem mora:

Religião (se tiver):

Telefone: Celular:

Naturalidade: Sexo:

Estado Civil:

Grau de Escolaridade:

02- DADOS DE INDENTIFICAÇÃO DOS PAIS:

Nome Pai: Idade:
Profissão: Empresa:
Grau de instrução:
Nome Mãe: Idade:
Profissão: Empresa:
Grau de instrução:
Endereço:
Celular: E-mail:
Estado civil:

03- QUEIXA PRINCIPAL:

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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05- QUEIXAS SECUNDÁRIAS:

 06- HISTÓRIA CLÍNICA:
Doença crônica:

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Uso de medicamentos. Quais:

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Casos de internação:

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Enfrentamento: _______________________________________________________________________

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Sintomas físicos e/ou psicológicos: ________________________________________________________

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Psicoterapia/fono/fisio/neuro/psiquiatria:
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Hábitos Alimentares:

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Para crianças ou adolescentes:

Condições de Nascimento:

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Desenvolvimento Neuropsicomotor:

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Doenças infantis:

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Casos de convulsões, epilepsia, desmaios etc.:

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07- HISTÓRIA FAMILIAR:

Em sua família alguém tem histórico com algum transtorno mental:

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Dinâmica Familiar: ____________________________________________________________________

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Eventos Significativos: ________________________________________________________________

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08- HISTÓRIA SOCIAL:

Vida Social:

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Hábitos de lazer:

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Inserção em Grupos:

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Rede de Apoio:

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Contatos da rede:

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09- DADOS ESCOLARES:

Casos de reprovação:

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Áreas de dificuldade:

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Hábitos de Estudo:

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10- CONSIDERAÇÕES FINAIS:

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