ROTEIRO DE ENTREVISTA INICIAL (ANAMNESE)

ADULTO

Data:_____/_____/_____                                                         Prontuário:_______________

Nome:_________________________________________________________________________________
Nome Social :___________________________________________________________________________
Data de nascimento:_____/______/______ Idade: ________  
Escolaridade/Escola:__________________________________ Série:________ Turno:_________________
Contatos de emergência:
Nome: ______________________________________________ Parentesco: ________________________ Tel:________________________________

Dados pessoais/familiares (com quem reside):

Nome Parentesco Idade

1. Motivo da consulta
1.1. Qual o motivo de sua vinda aqui, buscando o atendimento psicológico?
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1.2. Desde quando você nota que está com esse(s) problema(s)
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1.3. Que circunstâncias existiram em relação ao início da mesma (causas)?

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1.4. Situação em que ocorre atualmente (onde, com quem)?
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1.5. Houve algum fator agravante dos sintomas? O quê?
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1.6. Houve alguma melhora? Se sim, qual a causa?
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1.7. Qual a atitude da família com relação ao(s) problema(s)?
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1.8. Outras queixas?
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2.  Tratamento prévio: Psicológico, psiquiátrico e/ou neurológico.
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2.1. Antecedentes patológicos na família (doenças físicas e mentais).
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3. História de Vida
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4. Religião ______________________________________________________________________________

5. Atividade social e Lazer_________________________________________________________________

6. Situação atual de vida___________________________________________________________________

7. História psicossexual
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8. Há mais alguma coisa que gostaria de acrescentar?
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9. O que espera do atendimento?
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10. Exame Mental: _______________________________________________________________________
11. Hipótese diagnóstica (CID-10):
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12.  Observações:
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13. Encaminhamento(s):
Atendimento individual ( )Avaliação Psicológica ( )

Campo Grande, MS, _____ de ______________ de __________.

______________________________                                 _______________________________ ESTAGIÁRIO(A)                                                                SUPERVISOR(A)
(Assinatura e carimbo)                                                          (Assinatura e carimbo)