Anamnese Psicológica

Anamnese Adulto
Data:_______________
Nome:________________________
______________________________
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Idade:_____________
Sexo:_______________
CPF:__________________________
__
Identidade:_____________________
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Endereço:______________________
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 Anamnese Psicológica

______________________________
______________________________
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Telefones para
Contato:_______________________
______________________________
_
Bairro:________________________
____
Cidade:________________________
________
Religião:______________________
_____
Escolaridade:___________________
________
 Anamnese Psicológica

Filhos (nome, idade e

sexo)_________________________
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Profissão:______________________
______________________________
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Est.Civil:___________________
Cônjuge (nome, idade, profissão,
escolaridade):___________________
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 Anamnese Psicológica

______________________________
______________________________
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Queixa
principal:______________________
______________________________
_______
______________________________
______________________________
____________________
______________________________
______________________________
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Fez terapia anteriormente? (citar qual
e
 Anamnese Psicológica

quando)_______________________
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______________________________
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Expectativas e objetivos do
paciente:_______________________
____________________
______________________________
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______________________________
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Sintomas
apresentados:___________________
 Anamnese Psicológica

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Doenças
físicas:________________________
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 Anamnese Psicológica

Estressores
psicossociais:___________________
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______________________________
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Funcionamento
global:________________________
_______________________

Data: _______________

Informações Pessoais
Nome: ________________________________________________________________________________
Idade: _____________ Sexo: _____________________ Estado Civil: _________________________
CPF: _______________________________ Identidade: __________________________________
Endereço: _____________________________________________________________________________
 Anamnese Psicológica
Bairro: ________________________________________ Ocupação: ____________________________
Religião: ___________________________ Escolaridade: ______________________________________
Telefones para Contato: __________________________________________________________________
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Primeira Consulta
Queixa principal: ________________________________________________________________________
______________________________________________________________________________________
Aparência e comportamento: ______________________________________________________________
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Avaliação de demanda: ___________________________________________________________________
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Histórico da Queixa
Início da problemática: ____________________________________________________________________
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Frequência e intensidade: __________________________________________________________________
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Tratamentos anteriores: ____________________________________________________________________
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Conceituação Psicológica do
Caso:_________________________
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 Anamnese Psicológica

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Transtornos psiquiátricos
anteriores:_____________________
_______________________
Transtornos psiquiátricos
familiares:_____________________
_______________________
Doenças Importantes que
teve:__________________________
______________________
Medicação que está
tomando:______________________
___________________________
 Anamnese Psicológica

Medicação alternativa (chás,

compostos,
etc.)__________________________
___________
Aplicação de Testes? Se sim, qual e
resultado:______________________
______________
______________________________
______________________________
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Histórico da Queixa
 Anamnese Psicológica

Quando se
iniciou:________________________
______________________________
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______________________________
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______________________________
______________________________
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Eventos traumáticos de
vida:__________________________
________________________
______________________________
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 Anamnese Psicológica

______________________________
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Eventos/fatores que precipitam ou
agravam
crises:_________________________
________
______________________________
______________________________
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Uso de drogas?
______________________________
______________________________
_
 Anamnese Psicológica

Tentativa de suicídio?
______________________________
_________________________
Focos de intervenção
psicoterápica:___________________
__________________________
Uso de fármacos: _________________________________________________________________________
_______________________________________________________________________________________

Queixas cognitivas
 Integridade sensorial
 Atenção e concentração
 Memória
 Outro: _______________________________________________________________________

Queixa afetivas/Emocionais
 Tomada de decisão  Humor
 Afetividade  Culpa
 Ansiedade  Agressividade
 Medo  Desânimo
 Luto  Outro: _________________________
 Raiva

Socialização, lazer e estilo de vida

 Anamnese Psicológica
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Antecedentes Familiares
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Relação/Dinâmica familiar
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Relação / Dinâmica familiar

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Eventos traumáticos de vida

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 Anamnese Psicológica

Experiências afetivas marcantes

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Outras informações importantes

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Hipótese diagnóstica inicial / Prognóstico

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Acompanhamento e tratamento
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 Anamnese Psicológica

Outras observações: ________________________________________________________________________

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Georgea Marcela Santos Cardoso
CRP 03/28339