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FICHA DE ANAMNESE
12 - 17 anos

IDENTIFICAÇÃO

Nome:_________________________________________________________________
Rua: ____________________________________________Bairro: ________________
_________________________CEP:___________________ Contatos: _____________

________________________________________________________ Sexo: M ( ) F ( )
Data de nascimento: ____/ ____/ ____ Idade: ______ anos ______ meses.
Escolaridade:___________________________________________________________

Nome do Pai: _____________________________________________ Idade: _______

Profissão:______________________________________________________________
Nome da Mãe: _____________________________________________ Idade: _______
Profissão: ______________________________________________________________
Irmãos(idades):__________________________________________________________
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Outros: _______________________________________________________________
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Queixa principal: _______________________________________________________

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Como a família lida com a queixa: __________________________________________

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Possibilidades de horários: ________________________________________________
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HISTÓRIA DO DESENVOLVIMENTO

▪ História pré e perinatal

Como descobriu a gravidez?_______________________________________________

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Planejada? _____________ Desejada? ___________ Preferência do sexo? __________
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Existe parentesco entre os pais? ( ) Sim ( ) Não. Qual o grau? ___________________

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O casal está junto a quanto tempo?____________________ Como é o relacionamento?
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Duração da gestação: ___________________________ Sinal de parto falso: ________

Uso de substancia química? _________________ Álcool? _________________ Outros:

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Teve algum problema (físico/emocional) durante a gravidez? ( ) Sim ( ) Não.
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▪ Condições do parto
Duração do trabalho de parto ___________________________ alta ao fim de ___ dias.
Tipo do parto: Cesariana ( ) Normal ( )

A criança permaneceu na U.T.I. Neonatal? ( ) Sim ( ) Não. Por quanto tempo?

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Mamou no peito? ( ) Sim. Por quanto tempo? _________________ ( ) Não. Por quê?
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Deformações de nascimento? ______________________________________________
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Convulsões? _______________________ Anoxia? ____________________________
Vómitos? ____________ Dificuldades de nutrição? _____________________________
Diagnóstico precoce de alguma doença? ______________________________________

▪ Desenvolvimento motor

Mostrou resposta à mãe ____________(Sorriu, firmou a cabeça, buscou contato visual)

Sentou-se independentemente com ______________.
Engatinhou com ______________.
Andou sozinho com ______________.
Comeu com a colher/ garfo e bebeu com copo com _____________.
Se vestiu sozinho(a) com _____________.
Tomou banho sozinho(a) com ____________.
Aprendeu ir ao banheiro sozinho(a) ____________(Controle dos esfíncteres).
Apresentou problemas de articulação vocal, de linguagem ou de comunicação?
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Outras aquisições: _______________________________________________________

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▪ Desenvolvimento socioemocional

Expressa as suas necessidades e emoções? ___________________________ Adapta-se

facilmente às situações em casa? _______________ E em outros locais? ____________
Reage favoravelmente a novidades? _________________________________________
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Como reage a ordens? ____________________________________________________

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Agressivo (a)? ( ) Sim ( ) Não. ____________________________________________
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Dependente? ( ) Sim ( ) Não. _____________________________________________

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Carinhoso/Calmo(a)? ( ) Sim ( ) Não. ______________________________________

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Tem amigos? ( ) Sim ( ) Não. Faz amizade com facilidade? _____________________

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Prefere estar só ou com parentes/amigos? ____________________________________
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Quais as atividades preferidas / Jogos/ Lazer? _________________________________
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Assiste? ( ) Sim ( ) Não. Quanto tempo por dia? ______________________________
O que gosta de assistir? ___________________________________________________
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Tem animal doméstico? ( ) Sim ( ) Não. Como é a relação? _____________________
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Apresenta ou apresentou curiosidade sexual? ( ) Sim ( ) Não. De que forma?

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Com quem? E onde costuma passar mais tempo? ______________________________

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Como normalmente é o humor? ____________________________________________
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Descreva um dia rotineiro: ________________________________________________
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Que horas os pais estão em casa? ___________________________________________
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Quais atividades faz junto com os pais? _____________________________________

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Relacionamento com o pai:________________________________________________
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Relacionamento com a mãe: _______________________________________________
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Relacionamento com irmãos: ______________________________________________
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Outros: _______________________________________________________________
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Há concordância entre os pais em relação a limites? ___________________________

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A família frequenta alguma instituição religiosa? ( ) Sim ( ) Não. Qual?

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Sono: ( ) Tranquilo ( ) Sonambulismo ( ) Agitado ( ) Fala dormindo ( )Bruxismo

Dorme às:_________________ Acorda às:________________.
Tem cama individual? ( ) Sim ( ) Não. Dorme sozinho? ( ) Sim ( ) Não.
Quem dorme no mesmo quarto? ____________________________________________
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Algo mais a acrescentar? ________________________________________________

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HISTÓRIA ESCOLAR
Como descreveria a adaptação e o desempenho escolar? _________________________
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Se não frequenta, por que? ________________________________________________
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Tem ajuda na lição de casa? ( ) Sim ( ) Não.

Obs.: __________________________________________________________________
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Reforço escolar? ( ) Sim ( ) Não.

Assiduidade: ___________________________________________________________
Atividades extracurriculares: ateliê de tempos livres?
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As atividades na sala são realizadas com mais frequência em situação:

Individual ( ) Em pares ( ) Em grupo ( )

Quais as atividades de sua preferência?_______________________________________

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Descreva o comportamento em sala de aula com os professores e com os colegas:
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Dificuldades de aprendizagem? ____________________________________________
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HISTÓRIA CLÍNICA

▪ Histórico Médico

Fatos marcantes da vida e da família incluindo acidentes: _______________________

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Doenças e/ou transtornos psiquiátricos familiares por parte de pai ou mãe? – Indicar
qual e a idade se iniciou: __________________________________________________
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▪ Paciente

Alguma doença ou transtorno psiquiátrico atualmente? _________________________

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Doença ou transtornos psiquiátricos anteriores:________________________________
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Faz uso de medicamento(s) de forma frequente? ( ) Sim ( ) Não. Qual (is)?
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Medicação alternativa (chás, compostos, etc.) _________________________________

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Aplicação de Testes? Se sim, qual resultado:

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Já realizou acompanhamento psicológico antes (Quando iniciou, quanto tempo, quando
encerrou)?
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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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Gostaria de mencionar algo que não foi perguntado? ________________________

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Dados de observação do entrevistador: ____________________________________

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Assinatura do profissional responsável pela
anamnese.