FICHA DE ANAMNESE

IDENTIFICAÇÃO

I. IDENTIFICAÇÃO DO CLIENTE:

Nome: Sexo:

Data de nascimento: Idade (anos):

Naturalidade: Estado civil:

Escolaridade: Profissão:

Endereço:

Nº: Bairro: Cep:

Telefones: E-mail:

RG: CPF: Convênio:

II. CONTATO DE REFERÊNCIA/EMERGÊNCIA:

Nome do contato de Referência: Parentesco:

Telefones: E-mail:

MOTIVOS QUE TROUXERAM A CONSULTA

QUEIXA PRINCIPAL:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

EVENTOS E FATOS QUE CONSIDERA COMO MAIS IMPORTANTES:

____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

HISTÓRIA DA SITUAÇÃO/PROBLEMA ATUAL

QUANDO COMEÇOU?
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

ONDE PERCEBEU O INÍCIO?

____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
COMO COMEÇOU?
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

HISTÓRIA PATOLÓGICA PREGRESSA

TEVE ALGUMA DOENÇA NA INFÂNCIA?
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

JÁ TEVE ALGUM ACIDENTE?

____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

JÁ FEZ ALGUMA CIRURGIA?

____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

FAZ USO DE ALGUMA MEDICAÇÃO? QUAIS?

____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

HISTÓRIA FAMILIAR
COMO É O CONTEXTO FAMILIAR NUCLEAR?
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

SITUAÇÃO RELACIONAL/AFETIVA:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

RELAÇÃO COM OS FAMILIARES:

____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

HISTÓRIA DE DOENÇA NA FAMÍLIA:

____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

HISTÓRIA SOCIAL
VOCÊ FUMA?
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

COMO SE RELACIONA COM BEBIDA ALCOÓLICA?

____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

OUTROS HÁBITOS NOCIVOS A SAÚDE:

____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

ATIVIDADES URBANAS, QUAL A FREQUENCIA E QUANTIDADE:

____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
VÍNCULOS AFETIVOS E RELACIONAIS:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

REDES DE APOIO/SUPORTE:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

Declaro estar ciente das informações acima.

Cliente: _____________________________________________________________________________________________________________

Assinatura: _______________________________________________

Local e Data: _______________________________________ Psicólogo (a): ________________________________

RELATÓRIO/OBSERVAÇÕES/DATA DE ALTA