Anamnese de adulto

Carlos Buando (Psicólogo clínico, orientador vocaciona)

Consultoria Académica
Consultoria Académica

Luanda/2021

Anamnése de Adulto

Nome:______________________________________________Idade:_____Sexo:____

Bairro:__________________Província:________________Telefone:_______________

Habilidade literária:_________________________Estado civil:___________________

Religião:_____________________Profissão:__________________________________

Filhos (nome, idade e sexo):________________________________________________

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Cônjuge (nome, idade e profissão:___________________________________________

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Queixa principal:________________________________________________________

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Secundária:_____________________________________________________________
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Histórico da queixa

Início:_________________________________________________________________
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Evolução:______________________________________________________________
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Sintomas:______________________________________________________________
Fatores que precipitam ou agrava a crise origem:_______________________________

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Intensidade:_____________________________________________________________

Ambinte onde ocorre os sintomas:___________________________________________

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Impácto na sua vida (social, familiar, trabalho, sexual:___________________________

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Prejuízo com (família, amigos, outros):_______________________________________

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Eles sabem do seu problema:_______________________________________________

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Terapia anterior:_____quando:_________________Terapeuta:____________________

Realidade atual:

Ajuda (familiar; amigos e outro)_____como:__________________________________

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Com quem vives:________________________________________________________

Tem apoiado:____como:__________________________________________________

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Relacionamento importante:

Pai:___________________________________________________________________
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Mãe:__________________________________________________________________
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Irmãos:________________________________________________________________
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Amigos:_______________________________________________________________
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Outros:________________________________________________________________
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Dinâmica familiar:_______________________________________________________

Doênças familiar:________________________________________________________

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Uso de drogas:____desde quando:___________________________________________

Eventos aliciante:________________________________________________________

Tentativa de suicídio:_____quando:__________________________________________

Porquê:________________________________________________________________

Doenças atual:__________________________________________________________

Tratamento:____aonde:_________________________médico:____________________
_____________Medicamentos:_____________________________________________
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Infância

Gravidez (ñ/planejada) Sim Não

Doença:___antes____depois:___qual:________________________________________
Amamentação

Peito:____mamadeira___outro:_____________________________________________

Estressores na Infância:____________________________________________________

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Transtorno ( sono, tiques, gagueira, sonambulismo, aprendizagem):_________________

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Adolescência

Experiências afetivas marcante:_____________________________________________

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Experiência sexual marcante:_______________________________________________

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Independência/emprego:___________________________________________________
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Experiência desagradável:_________________________________________________

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Amizades:______________________________________________________________

Vida adulta

Relacionamento com parceiro:______________________________________________

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Vida sexual atual:________________________________________________________

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Situação financeira:_______________________________________________________

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Aborto/ espontânio provocado

Transtorno ( sono, alimentação, tiques):_______________________________________

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Lazer (hobbies)__________________________________________________________

Vício:_________________________________________________________________
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Apoio desponível:________________________________________________________

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Espectativas do tratamento:_________________________________________________

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Frequencia do atendimento:________________________________________________

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Outras observações

Verbal:________________________________________________________________
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Não verbal:_____________________________________________________________

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Data:_____/______/______ Local___________________________________________

Psicólogo:______________________________________________________________

Telefone:_____________/_____________/ Email:______________________________

Facebook:____________________________________Watsapp:__________________

Psicólogo

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 Análise

Sintomas apresentados:____________________________________________________

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Humor apresentado:______________________________________________________

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Comportamento

Coperativo Pouco coperativo Não coperativo

Outras observações comportamental:_______________________________________

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Transtornos na infância:_________________________________________________

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Transtorno na adolescêcia:________________________________________________

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Transtorno atual:_______________________________________________________

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Transtorno na família:___________________________________________________

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Doenças físicas:_________________________________________________________

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Tratamentos em curso:___________________________________________________

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Hipóteses diagnósticas

Hipótese (1):____________________________________________________________

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Hipótese (2):____________________________________________________________

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Hipótese (3):____________________________________________________________

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Planejamento da avaliação

Testes:________________________________________________________________

Outros instrumentos de avaliação:___________________________________________

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Referências bibliográfica dos instrumentos de avaliação

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Data da avaliação:_____/______/______ Hora:____:____

Data da avaliação:_____/______/______Hora:____:_____

Data da avaliação:_____/______/______Hora:____:_____

Data da avaliação:_____/______/______Hora:____:_____

Tempo total de avaliação:______________________horas:______:_______

Local da avaliação:_______________________________________

Psicólogo

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 Resultado da avaliação

Hipóteses testadas (resultado)

Hipótese (1):____________________________________________________________

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Hipótese (2):____________________________________________________________

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Hipótese (3):____________________________________________________________

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Resultado dos testes:______________________________________________________

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Diagnóstico

Eixo I:_________________________________________________________________

Eixo II (doenças físicas):_________________________________________________

Eixo IV(estressores psicossocial):__________________________________________

Eixo V (funcionamento global):____________________________________________

CID 10________________________________________________________________

Psicólogo:______________________________________________________________

Encaminhamento ou atendimento:_________________________________________

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 Conceituação do caso

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Data:____/____/_____

Psicólogo

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 Entrevista devolutiva

Nome:_________________________________________________________________
Idade____Sexo:____Estado civil:___________Nacionalidade:__________________

Bairro:_________________________________Telefone:_______________________

Descrição da demanda:

Motivo da consulta:

Recursos de avaliação:

Consntatou-se que:

Dificuldades:
Pontencialidades:

Pontos a ser trabalhados

Áreas: (social, cognitiva, comportamento interpessoal)

Resultado da avaliação:
 Laudo psicológico

Nome:_________________________________________________________________
Idade____Sexo:____Estado civil:___________Nacionalidade:__________________

Bairro:_________________________________Telefone:_______________________

Local de atendimento:___________________________________________________

Motivo da consulta:

Descrição da demanda:

Testes utilizados:

Resultados:

Diagnóstico:
 Entrevista ( pai, mãe, amigos, filhos, outros)

Entrevistado:___________________________________________________________I
dade:____Sexo:_____Grau:_________Data____/_____/______

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Local da entrevista:_______________________________________________________

Psicólogo:______________________________________________________________
 Pauta

Sessão nº:

Tema da pauta:__________________________________________________________

Data:____/____/_____Local:_______________________________________________

Objetivo da sessão:_______________________________________________________

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Humor:________________________________________________________________
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Atualização:____________________________________________________________
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Discutir o diagnóstico:____________________________________________________

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Identicar o problema:_____________________________________________________

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1(p):__________________________________________________________________
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2(p):__________________________________________________________________
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3(p):__________________________________________________________________
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Psicólogo:______________________________________________________________
 Pauta

Sessão nº:

Tema:_________________________________________________________________
Data:______/_____/_____Objetivos da sessão:_________________________________

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Histórico Escolar

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Vocação e trabalho

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Religiosa/espiritual

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