ROTEIRO DE ANAMNESE

1. IDENTIFICAÇÃO:

NOME: _________________________________________________________________________________ IDADE: _________

NATURAL DE: _____________________ NASCIMENTO: ____ / ____ / _______ ESTADO CIVIL: ______________________

ESCOLARIDADE: __________________________________________ ___________________________________

ENDEREÇO RESIDENCIAL: _______________________________________________________________________________

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TELEFONES PARA CONTATO:( ) ___________________; ( ) ___________________; ( ) ____________________

2. MOTIVO DA PROCURA AO PSICÓLOGO (QUEIXA PRINCIPAL E SECUNDÁRIA):

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3. EXPECTATIVA COM A PSICOTERAPIA:

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4. TRATAMENTOS ATUAIS / FARMACOLOGIA UTILIZADA:

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5. HISTÓRICO DAS DIFICULDADES RELATADAS:

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6. ANTECEDENTES FAMILIARES:

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7. DINÂMICA DE RELACIONAMENTO:

FAMILIAR:___________________________________________________________________________________________

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SOCIAL / LAZER: _____________________________________________________________________________________

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ESCOLAR / PROFISSIONAL: ____________________________________________________________________________

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8. ANTECEDENTES PESSOAIS:

GESTAÇÃO / NASCIMENTO: ___________________________________________________________________________

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DOENÇAS DE INFÂNCIA / INTERNAÇÕES: ______________________________________________________________

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ALIMENTAÇÃO / HÁBITOS E MANIPULAÇÕES: _________________________________________________________

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9. DESENVOLVIMENTO EMOCIONAL:

AFETIVIDADE / AGRESSIVIDADE: ____________________________________________________________________

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SEXUALIDADE / SONO / MEDOS / AUTORIDADE E LIMITE DOS PAIS:

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10. SAÚDE FÍSICA (PESSOAL / FAMILIAR):

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11. ASPECTOS SIGNIFICATIVOS PERCEBIDOS e ORIENTAÇÃO TERAPÊUTICA:

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Teresina – PI, ______ de _________________________ de __________

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PSICÓLOGO (A)