ANAMNESE ADOLESCENTE (Responsável)

DADOS DE IDENTIFICAÇÃO:

Nome: ______________________________________________________ Data: ___/___/___

Sexo: ( )M ( )F Idade: _________________ Data de Nascimento: ___/___/___
Estado Civil: ________________ Naturalidade: ________________ Moradia: _______________
Religião: ______________ Escolaridade: ___________________ Profissão:________________
Endereço:_____________________________________________________________________
Bairro: ________________ Cidade: ___________________ Telefone: ____________________

O que fez com que você procurasse tratamento? Por quê?

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DADOS DO NÚCLEO FAMILIAR:
Pessoas que moram na casa?
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Idade e ocupação de cada um?
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Como você avalia as relações familiares?
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Como é a relação com cada membro da família?
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Doenças psicológicas ou fisiológicas nos membros da família?
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Trauma (abuso sexual, psicológico, maus tratos)?
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Perdas significativas?
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CONDIÇÃO ATUAL
Alguém possui alguma doença na família? Qual?
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Em caso positivo, como convive com a doença?
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Quais os interesses (coisas, atividades ou pessoas que gosta ou já gostou anteriormente) do
paciente?
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Atualmente trabalha em outra atividade? Se sente satisfeito em seu trabalho atual?
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Já pensou em se matar? Já tentou? Quando foi a última vez que o mesmo tentou?
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DESCRIÇÃO DO COMPORTAMENTO PROBLEMA
Sintomas e quando iniciou, onde ocorre, com que frequência:
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O que pensa sobre ele (crenças sobre o problema)?
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O que lhe causa mal estar físico (estados fisiológicos)?

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O que você faz que o ajuda a controlar o problema, mesmo que surta pouco efeito? Exemplo?
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Atualmente, o paciente faz uso de alguma medicação? Como se sente quando faz uso?
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Quais as consequências positivas (ganho secundário) e negativas do
comportamento-problema?
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O que o problema o impede de fazer?
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HISTÓRIA DE VIDA
1. História pré e perinatal a) Gestação Planejada? Desejada? Pré-natal?
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Como foi a gestação (Ocorrência de eventos importantes)?

Doenças/hospitalizações:
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A mãe fez uso de drogas, medicação? Especificar:

Abortos? Quantos? Causa:
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b) Parto
( ) Normal ( ) Cesariana
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Relação conjugal dos pais nesse período:

Condição econômica/social/cultural:
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2. Desenvolvimento do (a) adolescente

Como ocorreu o desenvolvimento? Fatos marcantes durante o desenvolvimento
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Como foi a entrada na escola?
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Como são as relações sociais?
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Hospitalizações/cirurgias:
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Perdas/separações/distanciamentos (Estranhou ficar longe dos responsáveis? Como se
adaptava a ambientes
diferentes)?
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3. Momento atual
Funções básicas
Sono:
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4 Alimentação:
Hábitos de higiene:
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4. História escolar
Dificuldades:
Repetência (quantas vezes? Em qual série/ano?):
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Relações interpessoais na escola:
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5. História familiar
Relação dos pais com o(a) adolescente/ Como é a relação do(a) adolescente com os pais?
Relação com irmãos, colegas, amigos e família:
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Conflitos entre os membros da família, conflitos intergeracionais:

Dependência/independência:
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Como o(a) adolescente lida com frustrações, imposição de regras, normas e limites em casa?
Ambiente doméstico
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Como é a casa?
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Onde ele(a) dorme? Tem seu próprio quarto?
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O(a) adolescente tem privacidade?
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Onde ele(a) gosta de estar? Com quem?
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Ele(a) realiza tarefas em casa? (Arrumar o quarto, ajudar na limpeza e organização, etc)
Relações sociais
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Círculo de amizades (escola/fora da escola):
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Relacionamentos íntimos e sexualidade:
Capacidade para se relacionar:
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Interesses sociais, culturais e de lazer (Gosta de passar o tempo com outras pessoas? O que
faz para se divertir?
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Com que frequência?)
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Relações com pessoas do mesmo sexo ou com sexo oposto:
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Liderança nos grupos a que pertence:
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Houve mudanças de interesses, de vestuário, de atenção, de memória, de concentração, de
fala, de caráter, de humor? Em que período?
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Qualidades positivas e negativas que os pais ou pessoas próximas relatam sobre adolescente:
Questões específicas da adolescência
Fuga de casa:
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Álcool/cigarro/ outras drogas (que drogas? Com que frequência?):
Obesidade:
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Transtornos alimentares (Anorexia, bulimia, transtorno de compulsão alimentar periódica):
Sentimentos de inferioridade:
Rebeldia:
Rejeição
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Se presentes como os pais ou responsáveis reagem (reagiram) ante essas questões?
Descreva a rotina do(a) adolescente durante a semana e o fim de semana
TRATAMENTO ANTERIOR
Fez algum tratamento? JÁ FEZ TERAPIA?
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Como foi o tratamento anterior e o relacionamento com o terapeuta?
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METAS
METAS DO TRATAMENTO:
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HABILIDADES DA FAMÍLIA PACIENTE:
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OBSERVAÇÕES

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Aparecida Martins P Gonçalves- CRP04/66211

Psicóloga clínica