ENTREVISTA DE ANAMNESE

Identificação pessoal

Nome: ___________________________________________________________________
Data de nascimento: __/__/___ Estado civil: ______________________________
Endereço: ________________________________________________________________
Profissão: _________________________Escolaridade:____________________________
Telefone: ( )_______________
Contato em caso de necessidade (familiar/amigo): ( )________________________

Queixa principal (o que te trouxe para a terapia?)

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Evolução da queixa

 Como começou:
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 Foi repentino ou gradual:

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 Sintomas:
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 Quais transformações ocorreram:
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Histórico Clínico

 Presença de doença crônica:

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 Uso de medicamentos contínuo? 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 (faz ou fez acompanhamento com algum
desses profissionais?):
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 Hábitos Alimentares (como está a alimentação?/ tem se alimentado muito ou
pouco?):
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 Hábitos de sono (como tem dormido?/ dorme muito ou pouco?/ sente que o sono tem
sido suficiente?):
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Histórico Familiar

 Composição Familiar (quem mora com você?):

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 Dinâmica Familiar (como é o relacionamento em casa?):
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 Eventos Significativos (algum episódio marcante com sua família?):
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 Rede de Apoio (com quem você sente que pode contar quando precisa?):
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Histórico Social

 Vida Social:
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 Hábitos de lazer:
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Considerações finais

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