Gisele Rodrigues

Psicóloga CRP 08/22651

ANAMNESE CASAL

IDENTIFICAÇÃO:
NOME:
Ele
Ela:
Data de Nascimento: Idade:
Ele
Ela:
Religião:
Ele
Ela:
Local de nascimento:
Ele
Ela:
Endereço:
Profissão:
Ele
Ela:
Religião:
Ele
Ela:
Telefone: E-mail:
Ele
Ela:
OBS: sobre psicotrópicos

MOTIVO DA CONSULTA E HISTORICO

QUEIXA PRINCIPAL:
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(45) 99967 0024 / 3096-2065

1
RUA GENERAL OSORIO, 1402 SL01, PARQUE SÃO PAULO-
WWW.PSICOLOGAGISELERODRIGUES.COM.BR
@PSICOLOGAGISELERODRIGUS
 Gisele Rodrigues
Psicóloga CRP 08/22651

EVOLUÇÃO DA QUEIXA:
-Início da queixa:______________________________________________________________________
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- Súbita ou progressiva:_________________________________________________________________
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- Quais as mudanças que ocorreram/ o que afetou:____________________________________________

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- Sintomas:___________________________________________________________________________
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QUEIXAS SECUNDÁRIAS:
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HISTORIA DO CASAL- como se conheceram, como se apaixonaram, pontos negativos e pontos

positivos
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(45) 99967 0024 / 3096-2065

2
RUA GENERAL OSORIO, 1402 SL01, PARQUE SÃO PAULO-
WWW.PSICOLOGAGISELERODRIGUES.COM.BR
@PSICOLOGAGISELERODRIGUS
 Gisele Rodrigues
Psicóloga CRP 08/22651

HISTÓRIA FAMILIAR:

-Composição Familiar:________________________________________________________________
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-Dinâmica Familiar:____________________________________________________________________
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-Eventos Significativos:________________________________________________________________
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HISTÓRIA SOCIAL:
- Vida Social:_________________________________________________________________________
- Hábitos de lazer: _____________________________________________________________________
- Inserção em Grupos:__________________________________________________________________
- Rede de Apoio:______________________________________________________________________

CONSIDERAÇÕES FINAIS:
____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

(45) 99967 0024 / 3096-2065

3
RUA GENERAL OSORIO, 1402 SL01, PARQUE SÃO PAULO-
WWW.PSICOLOGAGISELERODRIGUES.COM.BR
@PSICOLOGAGISELERODRIGUS