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Anamnese Completa Adulto

Nome: __________________________________________________________________________
Idade:______ Sexo: M ( ) F ( ) CPF:__________________ Identidade:_____________________
Endereço:________________________________________________________________________
Bairro:____________________________ Cidade:__________________ Religião:_____________
Telefones para Contato:_____________________________________________________________
Escolaridade:_____________________________________________________________________
Filhos (nome, idade e sexo)___________________________________________________
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Profissão:________________________________________________________________________
Est.Civil:___________________ Cônjuge (nome, idade, profissão, escolaridade): ______________
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Queixa principal:__________________________________________________________________
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Sintomas apresentados:_____________________________________________________________
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Fez terapia anteriormente? __________________________________________________________
Expectativas e objetivos do paciente: __________________________________________________
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Possibilidade de horários: ___________________________________________________________
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:__________________________________________________

Transtornos psiquiátricos familiares: __________________________________________________
Doenças Importantes que teve:_______________________________________________________
Medicação que está tomando:________________________________________________________
Medicação alternativa (chás, compostos, etc.) ___________________________________________
Aplicação de Testes? Se sim, qual resultado: ___________________________________________
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Histórico da Queixa

Quando se iniciou:_________________________________________________________________
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Eventos traumáticos de vida:_________________________________________________________
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Eventos/fatores que precipitaram ou agravam crises: _____________________________________
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Uso de drogas? ___________________________________________________________________

Tentativa de suicídio? ______________________________________________________________
Focos de intervenção psicoterápica:___________________________________________________
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Relacionamentos Importantes

Conjuje:_________________________________________________________________________
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Mãe:____________________________________________________________________________
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Pai:_____________________________________________________________________________
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Irmãos:__________________________________________________________________________
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Filhos:__________________________________________________________________________
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Outros importantes:________________________________________________________________
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Observações sobre dinâmica familiar atual:_____________________________________________

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Infância

Gravidez (planejada ou não), parto, intercorrências obstétricas:______________________________

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Amamentação:____________________________________________________________________
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Treinamento de Higiene:____________________________________________________________
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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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Outros comentários:________________________________________________________________
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Adolescência

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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Abortos espontâneos/provocados:_____________________________________________________
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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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Observações e linguagem não verbais do paciente

Observações:_____________________________________________________________________
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Atendimentos Prestados
Profissional:______________________________________________________________________

Encaminhamentos Feitos:___________________________________________________________
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Terapêutica Utilizada (prescrição de exercícios, leituras, relaxamento, etc.): ___________________
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Assinatura do profissional responsável pela

anamnese