ANAMNESE

ADULTO

Nome e idade: _______________________________________________________

Data: _________________________ Nº Prontuário: _________________________

Encaminhado por: ____________________________________________________

DADOS
Data de nascimento: ______________________ Gênero: ( ) F ( )M

Escolaridade: ______________________ Ocupação: ________________________

Tel fixo: ___________________________ Celular: __________________________

Recado: ___________________________ Falar com: ________________________

Endereço: ___________________________________________________________

Número de Pessoas que moram na mesma residência: _______________

Nome Parentesco

Queixa/Motivo da consulta: _____________________________________________

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HISTÓRIA CLÍNICA

Momento do aparecimento do problema: ___________________________________

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Preocupação em relação à queixa: _______________________________________

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Perdas e ganhos secundários: ___________________________________________

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Áreas atingidas (familiar, social, ocupacional, escolar): ________________________

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Rede de apoio: _______________________________________________________

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Relacionamentos afetivos e sexualidade: __________________________________

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História psiquiátrica pregressa e uso de medicamentos: _______________________

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Tratamento psicológicos anteriores: ______________________________________

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História de vida no contexto familiar: ______________________________________

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História infantil: _______________________________________________________

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Rotina: _____________________________________________________________

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Expectativa em relação ao acompanhamento psicológico: _____________________

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Observações: ________________________________________________________

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Profissional Responsável