PSICÓLOGA

Anamnese Completa
Nome:_________________________________________________________________
Idade:_____________ Sexo:_______________
CPF:____________________________
Identidade:_______________________________
Endereço:______________________________________________________________
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Telefones para
Contato:______________________________________________________
Bairro:____________________________
Cidade:________________________________
Religião:___________________________
Escolaridade:___________________________
Filhos (nome, idade sexo)
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Profissão:_____________________________________________________________
Est.Civil:___________________
Cônjuge (nome, idade, profissão, escolaridade):
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Queixa principal:
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Possibilidade de horários:
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Fez terapia anteriormente? (citar qual e quando)
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 PSICÓLOGA

Expectativas e objetivos do paciente:

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Sintomas apresentados:
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Doenças físicas:
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Estressores psicossociais:
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Funcionamento global:
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Conceituação Psicológica do Caso:

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Transtornos psiquiátricos anteriores:

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Transtornos psiquiátricos familiares:

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Doenças Importantes que teve:

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 PSICÓLOGA

Medicação que está tomando:

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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?
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Tentativa de suicídio?
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Focos de intervenção psicoterápica:

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 PSICÓLOGA

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Relacionamentos Importantes

Conjuje:_______________________________________________________________
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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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 PSICÓLOGA

Observações sobre dinâmica familiar atual:

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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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 PSICÓLOGA

Outros comentários:
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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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Apoio Social disponível:

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 PSICÓLOGA

Principais lazeres, vida social:

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Observação e Linguagem Não verbal do Paciente

Observações:
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Atendimentos Prestados

Profissional:____________________________________________________________

Encaminhamentos Feitos:
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