Carla Dias Prontuário

Psicóloga

Ficha de Anamnese
IDENTIFICAÇÃO PESSOAL
Nome: ______________________________________________________________
Data de nascimento: ___________________ Sexo: _______________________
Endereço: ___________________________________________________________
______________________________________________________________________
Profissão: ______________ Religião: ____________ Escolaridade: __________
____________ Telefone: _______________ E-mail: _________________________

IDENTIFICAÇÃO DO RESPONSÁVEL
Nome: ______________________________________________________________
Data de nascimento: ___________________ Sexo: _______________________
Endereço: ___________________________________________________________
______________________________________________________________________
Profissão: ______________ Religião: ____________ Escolaridade: __________
____________ Telefone: _______________ E-mail: _________________________

QUEIXA PRINCIPAL
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
 Carla Dias
Psicóloga

EVOLUÇÃO DA QUEIXA
Como Começou:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Foi repentino ou gradual?

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Sintomas:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

OBSERVAÇÕES
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Cidade __________ / Data ____________________

______________________________________________________
Psicólogo e CRP