PREFEITURA MUNICIPAL DE MIRASSOL

Estado de São Paulo

DEPARTAMENTO MUNICIPAL DE SAÚDE
CAPS I (Centro de Atenção Psicossocial)
Rua Dos Galavottis nº 1221 – Karina 1808 - (0**17) 3242-8498
Home-page: www.mirassol.sp.gov.br e-mail: caps@mirassol.sp.gov.br

Anamnese Completa do Adulto

Nome:______________________________________________________________________
Idade:_____________ Sexo:_________________
Endereço:_______________________________________________________________________
Telefones para Contato:____________________________________________________________
Bairro:____________________________ Cidade:______________________________________
Religião:___________________________ Escolaridade:__________________________________
Filhos (nome, idade e sexo)__________________________________________________________
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Profissão:________________________________________________________________________
Est.Civil:________________________________________________________________________
Cônjuge (nome, idade e profissão):____________________________________________________
Queixa principal:__________________________________________________________________
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Possibilidade de horários:___________________________________________________________
Fez terapia anteriormente? (citar qual e quando)_________________________________________
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Expectativas e objetivos do paciente:__________________________________________________
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Sintomas apresentados:_____________________________________________________________
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Parte I – Diagnóstico

Eixo I:__________________________________________________________________________
Eixo II:__________________________________________________________________________
Eixo III (doenças físicas):___________________________________________________________
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Eixo IV (estressores psicossociais):___________________________________________________
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Eixo V (funcionamento global):______________________________________________________

Conceituação Psicológica do Caso:____________________________________________________

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Transtornos psiquiátricos anteriores:___________________________________________________
Transtornos psiquiátricos familiares:__________________________________________________
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Doenças Importantes que teve:_______________________________________________________
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Medicação que está tomando:________________________________________________________
Medicação alternativa (chás, compostos, etc.)___________________________________________
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Aplicação de Testes? Se sim, qual e resultado:___________________________________________
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Histórico da Queixa
Quando se iniciou:_________________________________________________________________
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Eventos traumáticos de vida:_________________________________________________________
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Eventos/fatores que precipitam ou agravam crises:_______________________________________
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Uso de drogas?___________________________________________________________________
Tentativa de suicídio?______________________________________________________________
Focos de intervenção psicoterápica:___________________________________________________
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Parte II – Relacionamentos Importantes

Mãe:______________________________________________________________________________
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Pai:_______________________________________________________________________________
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Irmãos:____________________________________________________________________________
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Filhos:____________________________________________________________________________
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Outros importantes:________________________________________________________________
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Observações sobre dinâmica familiar atual:_____________________________________________
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Parte III – Infância

Gravidez (planejada ou não), parto, intercorrências obstétricas:______________________________

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Amamentação:______________________________________________________________________
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Treinamento de Higiene:____________________________________________________________
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Estressores na infância, crises:_______________________________________________________
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Outros transtornos infantis (sono, alimentação, psicomotor, gagueira, tiques, sonambulismo,
aprendizagem):___________________________________________________________________
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Outros comentários:________________________________________________________________
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Parte IV – Adolescência

Experiências afetivas marcantes:______________________________________________________

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Experiências sexuais marcantes:______________________________________________________
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Independência/ primeiros empregos:___________________________________________________
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Círculo de amizades:_______________________________________________________________
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Parte V – Vida Adulta

Relacionamento com parceiro:_______________________________________________________

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Vida Sexual Atual:________________________________________________________________
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Situação Financeira:_______________________________________________________________
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Abortos espontâneos/provocados:_____________________________________________________
Apoio Social disponível:____________________________________________________________
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Outros transtornos atuais (sono, alimentação, tiques,etc.):__________________________________
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Principais lazeres, vida social:________________________________________________________
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Parte VI – Observação e Linguagem Não verbal do Paciente

Observações:_______________________________________________________________________
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Parte VII – Atendimentos Prestados

Profissional:______________________________________________________________________

Encaminhamentos Feitos:___________________________________________________________
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Terapêutica Utilizada (prescrição de exercícios, leituras, relaxamento, etc.):___________________

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Destino do caso:
Alta ( )
Encaminhamento a outra instituição ( ) Qual __________________________________________
Abandono ( ) Motivo_____________________________________________________________
Encaminhamento a outro profissional ( ) Quem _________________________________________
Interrompido ( ) Por que___________________________________________________________

Melhoras Obtidas:_________________________________________________________________
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Outras Observações Importantes:_____________________________________________________

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