Anamnese

I – Identificação
Nome:__________________________________________________________
Idade: __________________ Data de Nascimento:_______/_______/_______
Sexo: ( )M ( )F ( )Outro Estado Civil: _________________________
Cônjuge (nome, idade e profissão):__________________________________
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Escolaridade:___________________________________
Curso:_________________ Faculdade: __________________ Período:_____
Telefone: __________________ Religião: _____________
Local de Trabalho:_______________________________________________
Naturalidade:_________________________
Endereço:_______________________________________________________
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Identificação dos pais

Nome do pai:____________________________________________________

Quantos anos? _______ Profissão: __________________________________

Nome da mãe:___________________________________________________

Quantos anos? _______ Profissão: __________________________________

Tem irmãos? Quantos:_____________________________________________

Histórico clínico

Já fez terapia anteriormente?________________________________________

Já foi ao psiquiatra?_____________ Quem?____________________________

Fez/faz uso de algum medicamento?___________

Quais? ________________________________________________________
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II – Queixa principal/sintomas/há quanto tempo: ______________________

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Evolução da queixa: ______________________________________________

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Eventos traumáticos de vida:________________________________________

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Eventos/fatores que precipitam ou agravam crises:_______________________

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Uso de drogas? __________________________________________________

Tentativa de suicídio? _____________________________________________

III – Histórico familiar de doenças psicológicas: ______________________

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IV- AMBIENTE DE TRABALHO OU ESTUDOS

Vai bem no curso ou trabalho? ( )Sim ( )Não

Dificuldade em relacionar-se? ( )Sim ( )Não

Quais?
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Amigos com facilidade? ____________________________________________

Adapta-se facilmente ao meio? ______________________________________

Prefere ficar só ou com amigos? _____________________________________

V- RELACIONAMENTOS IMPORTANTES

Mãe:___________________________________________________________
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Pai:____________________________________________________________
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Irmãos:_________________________________________________________
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Filhos:__________________________________________________________
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Relacionamento com parceiro(a):_____________________________________

Vida sexual atualmente:____________________________________________

Situação financeira:_______________________________________________

Principais lazeres, vida social:_______________________________________

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VI- Histórico Pessoal:

Infância/
adolescência:____________________________________________________
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Rotina__________________________________________________________
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Hobbies:________________________________________________________
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