ANAMNESE ADULTO

Nome completo:_______________________________________________________________
Data da primeira consulta: _____/_____/_______
Naturalidade:_____________ Data de Nascimento: ____/____/____ Grau de instrução:_______
Profissão:________________________________ Telefone residencial ( ): ________________
Telefone Celular ( ): _________________________
Local de trabalho:______________________________________________________________
Composição familiar:___________________________________________________________

Nome Idade Instrução Profissão Relação de

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QUEIXA INICIAL
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Autoconceito (Como o(a) cliente se vê hoje):

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 HISTÓRICO DE SAÚDE (Orgânicos e Psíquicos)

a) Doenças na infância:
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b) Acidentes:
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c) Tratamentos (médico, psicológico, neurológico, etc):

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d) Uso de medicamentos (quais, desde quando, prescrições, etc):
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e) Problemas fisiológicos: (inclusive dores de cabeças, intestinais, alergias, deficiências

visuais, auditivas e outras).
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f) Doenças em outros membros da família:

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HISTÓRIA DE SONO E VIGÍLIA

1) Como é o seu sono? (Em caso de problemas (insônia, dificuldades de dormir, acordar,
pesadelos, etc.) no sono, fazer as perguntas abaixo):
1.1) Horário de dormir: _______________________________________________________
1.2) Horário de acordar: ______________________________________________________
1.3) Dorme com facilidade? ___________________________________________________
1.4) Problemas durante o sono? (fala, interrompe, levanta, apneia, etc.):
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1.5) Pesadelos:
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1.6) Medicamentos para dormir (tipo, frequência, ocasião, etc.):

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1.7) Medos noturnos:

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ROTINA DIÁRIA

a) Sequência desde o acordar (de 2a à 6a feira):

Manhã:
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Tarde:
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Noite:
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b) Fins de semana e feriados:
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c) Nas férias:
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ALIMENTAÇÃO

1) Dificuldades de alimentação ou apetite?

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RELAÇÕES AFETIVO-FAMILIARES (inclui vida doméstica, como foi e como é)

a) Relação com pai:

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b) Relação com a mãe:

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c) Relação com os irmãos:

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d) Relação com outros parentes e/ou moradores:

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RELAÇOES DE AMIZADE

a) Tem amigos(as)? Muitos(as), alguns(mas) especiais?

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b) Tem facilidade em manter as amizades?

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c) Tem facilidade de fazer novos amigos?

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HISTÓRIA EDUCACIONAL

a) Existe algum dado relevante na sua história escolar que você deseja mencionar?
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b) Qual sua atitude costumeira em relação ao estudo?

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LAZER

a) Quais atividades você gosta de fazer?

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b) Quais atividades você gosta, mas não faz?

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VIDA PROFISSIONAL

a) Quais profissões e/ou empregos exercidos (quando, onde):

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b) Grau de satisfação nestas atividades (vocações e motivações inclusive financeiras):

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c) Como são as relações no ambiente de trabalho?

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d) Projetos profissionais (realizados e por realizar):

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e) Traz trabalho para casa?

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f) O trabalho interfere na vida afetivo-familiar?

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VIDA RELIGIOSA

a) Você tem ou não? Qual?

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b) Desde quando, influência, como se sente, por quê?

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c) Como eram e ainda são as relações sociais com os demais fiéis?
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VIDA SEXUAL

a) Quando e como começou (voluntariamente, foi prazeroso?):

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b) Frequência e mudança de parceiro:

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c) Preferências (tipos de parceiro e atividade):

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d) Dificuldades:
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e) Grau de satisfação:
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f) Aversões:
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g) Educação sexual (como foi, como a família de origem encara(va) o sexo):

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EXPECTATIVAS QUANTO A TERAPIA:

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Data e horário dos atendimentos estipulados no contrato:
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OBSERVAÇÕES/ ENCAMINHAMENTOS NECESSÁRIOS :

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