MÓDULO 2 – PRÁTICA CLÍNICA

Consultório Empresa

ANEXO 3 - FICHA DE PRIMEIRA CONSULTA

Data:___/___/______
Nome: __________________________________________________________________________
Idade: _____ Estado Civil: ________________________ Profissão: ______________________
Telefone: _______________________________________ Celular: ( ) _____________________

Motivo da Consulta: _______________________________________________________________

Quem encaminhou: _______________________________________________________________

Terapias anteriores? ( ) Sim ( ) Não Quanto tempo? _______________________________

Toma algum medicamento controlado? ( ) Sim ( ) Não
Qual(is) ? ________________________________________________________________________
Motivo: __________________________________________________________________________
Alguma doença atual ou anterior (doenças graves, acidentes, cirurgias)? ( ) Sim ( ) Não
Qual(is) ? ________________________________________________________________________
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História da moléstia atual (o que o traz aqui, o que sente).

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História pregressa (o que já aconteceu em sua vida, quando começou sentir o que queixa,
o que mudou em sua vida desde o acontecido que te trouxe até aqui).
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 MÓDULO 2 – PRÁTICA CLÍNICA
Consultório Empresa

ANEXO 3 - FICHA DE PRIMEIRA CONSULTA

História familiar (infância, pais, com quem mora, doenças familiares, algum conflito maior
perda de parentes, tragédias, desafios, maiores afinidades, sente orgulh,o etc)
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Desenvolvimento Emocional: Algo especial? Algum trauma?

Infância: _________________________________________________________________________
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Adolescência: ____________________________________________________________________
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Idade Adulta: _____________________________________________________________________
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Memória boa? ( ) Sim ( ) Não _____________________________________________________

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Concentração é boa? ( ) Sim ( ) Não _______________________________________________
Como é o seu sono? _______________________________________________________________
Como é sua alimentação? __________________________________________________________
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Como é na escola/trabalho? ________________________________________________________
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Como é o relacionamento com Pai? _________________________________________________
Como é o relacionamento com Mãe ? _________________________________________________
Como é o relacionamento com Namorado(a)/Esposo(a) ? _______________________________
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 MÓDULO 2 – PRÁTICA CLÍNICA
Consultório Empresa

ANEXO3 - FICHA DE PRIMEIRA CONSULTA

Algo específico a relatar?
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Hipótese diagnóstica (HD)

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Tratamento - estratégias (O que fazer?)

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Comentários adicionais:
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 MÓDULO 2 – PRÁTICA CLÍNICA
Consultório Empresa

ANEXO 4 - FICHA CADASTRAL DO CLIENTE

Nome: ____________________________________________ Data Nascimento: ___/___/_____
CPF: ____________________________________________ Identidade: __________________
Estado Civil: ________________________________________________________________________
Profissão: _______________________________________________ Série: __________________
Grau de instrução: ________________________________________________________________________
Filiação - Mãe: ________________________________________________________________________
Pai: ________________________________________________________________________
Endereço: ________________________________________________________________________
No. ________ Complemento: ______________________________________________
Bairro: __________________________________________________________________
CEP.: ________-_____ Cidade: _____________________________ Estado: ___________
Telefones: Residencial: ________________ Comercial: ____________________________________
Celular: ______________ Email: _____________________________________________
Condição sócio econômica: ___Ativo ___Inativo ___Aposentado ___Dependente ___Desempregado
Tem irmâos ? Quantos ____ Quem são: __________________________________________________
Indicação: ____________________________ Internet: ____________________________
Recibo: Nome de quem: __________________________________________________________
CPF: ____________________________________________________________________
Horário de preferência: ___Manhã ___Tarde ___Noite

1a entrevista: Data: ___/___/___ Hora: ________ ___Compareceu __Faltou __ Desmarcou

Remarcou ___ Data: ___/___/___ Hora: _______
Pagamento: ___por sessão Valor da sessão: ___________________________
___mensal Dia: _____________________________________
Início da terapia: ___/___/___ Término da terapia: ___/___/____
Encaminhamento: ________________________________________________________________________
Comentários: ________________________________________________________________________
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 MÓDULO 2 – PRÁTICA CLÍNICA
Consultório Empresa

ANEXO 5 - REGISTRO DOS ATENDIMENTOS

Cliente: _______________________________________________________________
Nº Atendimento: ________ Tema: _______________________________________________
Data:___/___/_______ _____________________________________________________
Demanda/Objetivo: _______________________________________________________________
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Técnicas utilizadas : _______________________________________________________________
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Tarefas: _________________________________________________________________________
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Nº Atendimento: ________ Tema: _______________________________________________

Data:___/___/_______ _____________________________________________________
Demanda/Objetivo: _______________________________________________________________
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Técnicas utilizadas : _______________________________________________________________
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Tarefas: _________________________________________________________________________
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Nº Atendimento: ________ Tema: _______________________________________________

Data:___/___/_______ _____________________________________________________
Demanda/Objetivo: _______________________________________________________________
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Técnicas utilizadas : _______________________________________________________________
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Tarefas: _________________________________________________________________________
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 MÓDULO 2 – PRÁTICA CLÍNICA
Consultório Empresa

ANEXO 6 - REGISTRO DE CLIENTE - CRP

1- Identificação do paciente: Data: ___/___/______

Nome: ___________________________________________________________________________
Endereço: ________________________________________________________________________
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Data de Nascimento: ___/___/______
Telefones - Resid. ( ) _____________ Com.( )_____________ Cel: ( ) __________________
Profissão: ________________________________________________________________________

2- Avaliação da demanda (queixa principal):

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3- Avaliação dos objetivos do trabalho (O que será feito):

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4- Registros da evolução do trabalhos:

(em anexo)

5- Encaminhamento ou encerramento:
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6- Documentos (testes, atestados, laudos...)

(em anexo)

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