ANAMNESE ADULTO

Nome:
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Idade:
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Sexo:
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Gênero:
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CPF:
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Identidade:
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Telefones para Contato:
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Endereço:
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Bairro:
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Cidade:
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Religião:
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Escolaridade:
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Filhos (nome, idade e sexo):
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Profissão:
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Estado civil:
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Cônjuge (nome, idade, profissão, escolaridade):
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QUEIXA PRINCIPAL:
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Possibilidade de horários:
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Fez terapia anteriormente? (Citar qual e quando):

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Expectativas e objetivos do paciente:
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Sintomas apresentados:
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Doenças físicas:
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Estressores psicossociais:
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Funcionamento global:
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Conceituação Psicológica do Caso:

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Transtornos psiquiátricos anteriores:
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Transtornos psiquiátricos familiares:

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Doenças Importantes que teve:

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Medicação que está tomando:

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Medicação alternativa (chás, compostos, etc.):

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Aplicação de Testes? Se sim, qual o resultado:

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 HISTÓRICO DA QUEIXA

Início:
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Eventos traumáticos de vida:

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Eventos/fatores que precipitam ou agravam crises:

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Já fez uso de drogas?

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Tentativa de suicídio?
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Focos de intervenção psicoterápica:

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 RELACIONAMENTOS IMPORTANTES

Cônjuge:
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Mãe:
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Pai:
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Irmãos:
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Filhos:
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Observações sobre dinâmica familiar atual:
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Estressores na infância, crises:

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Outros transtornos infantis (sono, alimentação, psicomotor, gagueira,
tiques, sonambulismo, aprendizagem):
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Adolescência:
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Experiências afetivas marcantes:

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Experiências sexuais marcantes:

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Independência/ primeiros empregos:

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Círculo de amizades:
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 VIDA ADULTA

Relacionamento com parceiro:

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Vida Sexual Atual:
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Situação Financeira:
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Apoio Social disponível:

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Outros transtornos atuais (sono, alimentação, tiques etc.):

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Principais lazeres, vida social:

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OBSERVAÇÃO E LINGUAGEM NÃO VERBAIS DO PACIENTE

OBSERVAÇÕES:
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Atendimentos Prestados
Profissional:
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Encaminhamentos Feitos:
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Terapêutica Utilizada (prescrição de exercícios, leituras, relaxamento

etc.):
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