ANAMNESE

I – IDENTIFICAÇÃO
Nome:______________________________________________________Idade: ____________
Data de Nascimento: ____/____/______ Sexo: M ( ) F ( ) Outro ( ) Civil: _______________
Profissão*: ___________________________________ Integral ( ) Parcial ( ) Não trabalha ( )
Escolaridade: __________________ Curso: _______________ Período: ___________
Religião*: ________________ Ambiente de vida:
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Situação socioeconômica:
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Possibilidade de horários: _____________________ Telefone para contato:
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II – CONCEITUALIZAÇÃO
Queixa principal/problemas presentes*:_____________________________________________
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Queixa secundária: _____________________________________________________________
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Sintomas Emocionais: __________________________________________________________
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Sintomas Cognitivos: ___________________________________________________________
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Sintomas Comportamentais_______________________________________________________
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Sintomas Fisiológicos: __________________________________________________________
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Frequência*: __________________________________________________________________
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Intensidade*: __________________________________________________________________
Algum diagnóstico?*: __________________________________________________________
Início da patologia*: ____________________________________________________________
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Tratamentos anteriores*:
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Atendimento psicológico/psiquiátrico anterior*? ______________________________________
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Uso de Psicotrópicos?*: _________________________________________________________
Efeitos colaterais: ______________________________________________________________
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Eventos/fatores que precipitam ou agravam crises:
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Uso de drogas?* _______________________________________________________________
Tentativa de suicídio?* __________________________________________________________
Expectativas ao procurar terapia/O que busca*:
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III – HISTÓRICO PESSOAL:

Infância:______________________________________________________________________
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Rotina/Funcionamento atual: (interação com a família/amigos/trabalho, funcionamento geral
nos ambientes dos quais faz parte, como passa o tempo livre, atividades de
prazer/realização/conexão, atividades de autocuidado, atividades que evita)*:
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Vícios: _______________________________________________________________________
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Hobbies: _____________________________________________________________________
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O que está indo bem? ___________________________________________________________
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Qual foi o melhor período da
vida*:_________________________________________________
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Como gostaria que sua vida fosse diferente?*
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Cognições
principais:____________________________________________________________
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Estratégias comportamentais:_____________________________________________________
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Fatores de manutenção de um transtorno:____________________________________________
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Valores: ______________________________________________________________________
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Atributos positivos:
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Pontos fortes: _________________________________________________________________
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Habilidades: __________________________________________________________________
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III – DADOS FAMILIARES (caso resida com os pais)

Nome do Pai: ________________________ Idade: ______ Profissão:
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Nome da Mãe: __________________________ Idade: ______ Profissão:
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N° de irmãos/ Sexo/ Idades*: _____________________________________________________
Posição no bloco familiar:
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Reside com:
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Pais: ( ) Casados ( ) Separados
Filho: ( ) Biológico ( ) Adotivo, Se SIM desde quanto?
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É ciente de sua adoção? ( ) Sim ( ) Não
Reação à situação:
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Dificuldades no relacionamento familiar?____________________________________________
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IV – ANTECEDENTES FAMILIARES
Alguém com problema mental na família? ( ) Sim ( ) Não, Qual e Quem?
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Alguém com vícios? ( ) Sim ( ) Não Qual/Quem? ____________________________________
Alguém com tiques? ( ) Sim ( ) Não Qual/Quem? ____________________________________

V - ANÁLISE COMPORTAMENTAL

Postura durante a entrevista: Introvertido ( ) Extrovertido ( ) Acentuado ( ) Compensado ( )

Aparência:____________________________________________________________________
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Comportamento: _______________________________________________________________
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Atitude durante a entrevista: Cooperativo ( ) Resistente ( ) Indiferente ( )
Atenção: _____________________________________________________________________
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Vigilância: ____________________________________________________________________
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Tenacidade: ___________________________________________________________________
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Memória:
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Inteligência: __________________________________________________________________

VI - ASPECTOS PARA O PSICODIAGNÓSTICO

Aflição pessoal: _______________________________________________________________

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Incapacidade ou disfunção:
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Violação de normas: ____________________________________________________________
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Raridade estatística: ____________________________________________________________
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Hipótese diagnóstica/Diagnóstico: _________________________________________________
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Plano de tratamento: ____________________________________________________________
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VII – DEMAIS ANOTAÇÕES (INFOS ADICIONAIS TRAZIDAS PELO PACIENTE)

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VIII – AFETAÇÃO DO AVALIADOR

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IX – RESUMO NARRATIVO, INCORPORAÇÃO DE DADOS DO HISTÓRICO