DATA: ___/___/___ ANAMNESE PSICOLÓGICA

DADOS PESSOAIS
NOME:
CPF: RG:
DATA DE NASCIMENTO: IDADE:
ENDEREÇO: CIDADE:
TELEFONE: ( ) WHATSAPP: ( )
NATURALIDADE: ESCOLARIDADE:
PROFISSÃO: RELIGIÃO:
HORÁRIO DE TRABALHO: E-MAIL PESSOAL:
ESTADO CIVIL: FILHOS:
QUEM SABE QUE ESTÁ NA TERAPIA? CELULAR: ( )
NOME DO PAI: TELEFONE:
NOME DA MÃE: TELEFONE:
NOME DE UMA PESSOA PRÓXIMA:
TELEFONE: ( ) VÍNCULO:

ENCAMINHAMENTO:
PROFISSIONAL RESPONSÁVEL:
LOCAL DE ATENDIMENTO PSICOLÓGICO:

IDENTIFICAÇÃO DOS PAIS

NOME PAI:
PROFISSÃO: GRAU DE INSTRUÇÃO:
IDADE: CIDADE QUE MORA:
NOME DA MÃE:
PROFISSÃO: GRAU DE INSTRUÇÃO:
IDADE: CIDADE QUE MORA:
PAIS ADOTIVOS: SIM ( ) NÃO ( ) GRAU DE PARENTESCO:

PRINCIPAL QUEIXA E PROBLEMAS ATUAIS

EVOLUÇÃO QUEIXA
-Prioridade/Meta: _______________________________________________________________________________
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- Início da Queixa:
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- Súbita ou progressiva: ___________________________________________________________________________

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Variação de humor:
- Quais mudanças ocorreram e como afetou (eventos desencadeadores):
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QUEIXAS SECUNDÁRIAS

HISTÓRIA CLÍNICA
Doença crônica:

Casos de internação:

Enfrentamento:

Sintomas físicos e/ou psicológicos: ________________________________________________________________

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Psicoterapia/Fono/Fisio/Neuro/Psiquiatra:____________________________________________________________
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Hábitos Alimentares:

- Para crianças ou adolescentes:

Condição de Nascimento: _________________________________________________________________________
Desenvolvimento Neuropsicomotor: ________________________________________________________________
______________________________________________________________________________________________
Doença Infantil: _________________________________________________________________________________
______________________________________________________________________________________________
Casos de convulsões, epilepsia, etc.: ________________________________________________________________
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SOCIAL/LAZER

Vida social:

Hábitos de Lazer:

Inserção em grupos:
Rede de apoio:

HISTÓRIA FAMILIAR

Composição familiar (genotograma):_________________________________________________________________

_______________________________________________________________________________________________
_______________________________________________________________________________________________
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Rede de apoio:

Eventos significativos: ____________________________________________________________________________

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DADOS ESCOLARES

Casos de Reprovação: ____________________________________________________________________________

______________________________________________________________________________________________

Áreas de dificuldade: ____________________________________________________________________________

______________________________________________________________________________________________

Hábitos de estudo: ______________________________________________________________________________

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SEXUALIDADE
Relação: _______________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

Gênero:

Traumas/Eventos Significativos: ____________________________________________________________________

______________________________________________________________________________________________
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 HISTÓRIA PSIQUIATRA

Tipos de tratamento psicossocial, hospitalização, medicação, tentativa de suicídio e situação atual:

_______________________________________________________________________________________________
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Histórico de doença psiquiatra na família (se sim, parentesco): ___________________________________________

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ÁLCOOL E OUTRAS DROGAS

Abuso de substâncias e situação atual:

_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
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AUTOIMAGEM

Pontos fortes e pontos fracos, valores, sonhos e estratégias adaptativas:

_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

RELIGIOSIDADE/ESPIRITUALIDADE
História espiritual e situação atual: ________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

OCUPACÃO
Rotina de trabalho/casa/tempo livre: _____________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
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 CONSIDERAÇÕES FINAIS
_______________________________________________________________________________________________
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SUGESTÕES E ENCAMINHAMENTO
_______________________________________________________________________________________________
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Psicóloga Karla Amaral

CRP 03/15532