HISTÓRIA DO USO DE SUBSTÂNCIAS PSICOATIVAS

Nome ________________________________________________________________________________________
Data do atendimento: __________________________________________________________________________

Uso de Substâncias Psicoativas na Vida

Álcool ( ) Maconha ( ) LSD ( ) Crack ( ) Anfetaminas ( ) _______________ ( )

Tabaco ( ) Inalantes ( ) Cocaína ( ) Ecstasy ( ) ___________ ( ) _______________ ( )

Último Consumo de Substâncias Psicoativas que o membro sabe:

1. _____________________________________ qtde ________________ data _____/_____/__________

Quais substância a pessoa faz ou fazia uso?__________________________________________________________________________________

EVOLUÇÃO DAS PRESSÕES E CIRCUNSTÂNCIAS (Substância 1)

Ambientes e circunstâncias do início do uso ____________________________________________________________

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Ambientes e circunstâncias em que o hábito de uso se modificou ___________________________________________

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EVOLUÇÃO DAS PRESSÕES E CIRCUNSTÂNCIAS (Substância 2)

Ambientes e circunstâncias do início do uso __________________________________________________________

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Ambientes e circunstâncias em que o hábito de uso se modificou _________________________________________

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ROTINA DE VIDA E CONSUMO

Atividades diárias
- manhã ______________________________________________________________________________________
- tarde ________________________________________________________________________________________
- noite ________________________________________________________________________________________

Rotina de consumo
- 1º consumo do dia / quantidade __________________________________________________________________
- Substância / quantidade de consumo por dia ________________________________________________________
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- locais preferenciais de uso _____________________________________________________________________
- Preferência do uso: solitário ou acompanhado______________________________________________________
- motivações do uso _____________________________________________________________________________
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- estado mental após o consumo ___________________________________________________________________

-estado mental após o efeito do uso ________________________________________________________________

-estado emocional após o consumo _________________________________________________________________________

-estado emocional após efeito do uso ________________________________________________________________________

GESTAÇÃO E PARTO

Dependência / uso de álcool e outras drogas por parte da mãe ___________________________________________

COMPLICAÇÕES CLÍNICAS

Doenças crônicas ou de repetição, na infância, adolescência e/ou atuais __________________________________

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Internações clínicas

idade período local Abstinência pós-internação

Cirurgias / acidentes relacionados ao consumo de álcool e/ou outras drogas __________________________

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COMORBIDADES PSIQUIÁTRICAS

Investigação diagnóstica específica ________________________________________________________________

Idade de início _________________________________________________________________________________

Evolução, remissão, recidiva ______________________________________________________________________

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Tratamentos realizados __________________________________________________________________________
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Relação com consumo (comorbidades) _____________________________________________________________

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Anotações ____________________________________________________________________________________

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PERSONALIDADE

Jeito de ser ___________________________________________________________________________________

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Pontos fortes (auto-estima) _______________________________________________________________________

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Pontos fracos __________________________________________________________________________________

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Objetivos de vida _______________________________________________________________________________

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Expectativa quanto aos relacionamentos

- parentes _____________________________________________________________________________________

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- amigos ______________________________________________________________________________________
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- chefes, professores e/ou autoridades ______________________________________________________________
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Aspectos que o incomodam em relação:

- a si mesmo________________________________________________________________________________
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- aos outros ___________________________________________________________________________________

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Proximidade com os outros _______________________________________________________________________

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Autocontrole ___________________________________________________________________________________

Impulsividade __________________________________________________________________________________

Irritabilidade ___________________________________________________________________________________

Conformismo __________________________________________________________________________________

Postura frente às regras _________________________________________________________________________

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Força de vontade _______________________________________________________________________________

Ambição ______________________________________________________________________________________

Determinação __________________________________________________________________________________

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Reação diante do estresse _______________________________________________________________________

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Relação entre o uso de drogas e os itens anteriormente referidos_______________________________________

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HISTÓRIA OCUPACIONAL

Relação entre a mudança de emprego e o consumo de álcool e/ou outras drogas ____________________________
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Assiduidade ___________________________________________________________________________________

Histórico das demissões e o(s) motivo(s) delas ______________________________________________________

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HISTÓRICO LEGAL

Infrações relacionadas ao consumo ________________________________________________________________

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Contravenções relacionadas ao consumo de drogas ilícitas ______________________________________________

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ANTECEDENTES FAMILIARES
Pais
Idade ________________________________________________________________________________________

Saúde física e mental ___________________________________________________________________________

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Morte ________________________________________________________________________________________
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Qualidade do relacionamento na história do casal _____________________________________________________
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Uso de drogas pelos pais ________________________________________________________________________

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Irmãos

Quantidade / idade(s) ___________________________________________________________________________

Status e papéis do(s) irmão(s) _____________________________________________________________________

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Qualidade do relacionamento _____________________________________________________________________

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Uso de álcool e outras drogas pelo(s) irmão(s) ________________________________________________________

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AMBIENTE NA INFÂNCIA

Qualidade do vínculo dos pais entre si______________________________________________________________

Separações ___________________________________________________________________________________

Estrutura da família _____________________________________________________________________________

Cuidados dispensados ao paciente _________________________________________________________________

Presença e influência das drogas no cotidiano familiar _________________________________________________

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DOENÇAS FAMILIARES

Transtornos psiquiátricos _________________________________________________________________________

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Transtornos relacionados ao consumo de substâncias psicoativas ________________________________________

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Pais, irmãos, tios, avós, primos ____________________________________________________________________
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Elytanya Vasconcelos
Psicóloga CRP 15/4146