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Anamnese Completa do Adulto Nome:____________________________________________________________________ Idade:_____________ Sexo:_______________ Endereço:__________________________________________________________________________________________________________________________________________ Telefones para Contato:______________________________________________________ Bairro:____________________________ Cidade:________________________________ Religião:___________________________ Escolaridade:___________________________ Filhos (nome, idade e sexo)___________________________________________________ _________________________________________________________________________ Profissão:_________________________________________________________________ Est.Civil:___________________ Cônjuge (nome, idade e profissão):_____________________________________________ Queixa principal:___________________________________________________________ __________________________________________________________________________________________________________________________________________________ Possibilidade de horários:____________________________________________________ Fez terapia anteriormente? (citar qual e quando)___________________________________ _________________________________________________________________________ Expectativas e objetivos do paciente:___________________________________________ __________________________________________________________________________________________________________________________________________________ Sintomas apresentados:______________________________________________________ __________________________________________________________________________________________________________________________________________________ Parte I – Diagnóstico Eixo I:____________________________________________________________________ Eixo II:___________________________________________________________________ Eixo III (doenças físicas):____________________________________________________ _________________________________________________________________________ Eixo IV (estressores psicossociais):_____________________________________________ _________________________________________________________________________ Eixo V (funcionamento global):________________________________________________ Conceituação Psicológica do Caso:_____________________________________________ __________________________________________________________________________________________________________________________________________________ Transtornos psiquiátricos anteriores:____________________________________________ Transtornos psiquiátricos familiares:____________________________________________ Doenças Importantes que teve:________________________________________________ Medicação que está tomando:_________________________________________________ Medicação alternativa (chás, compostos, etc.)_____________________________________ Aplicação de Testes? Se sim, qual e resultado:____________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________ Histórico da Queixa Quando se iniciou:__________________________________________________________ __________________________________________________________________________________________________________________________________________________ Eventos traumáticos de vida:__________________________________________________ __________________________________________________________________________________________________________________________________________________ Eventos/fatores que precipitam ou agravam crises:_________________________________ _________________________________________________________________________ Uso de drogas?_____________________________________________________________ Tentativa de suicídio?_______________________________________________________ Focos de intervenção psicoterápica:_____________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________ Parte II – Relacionamentos Importantes Mãe:______________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________ Pai:_______________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________ Irmãos:____________________________________________________________________________________________________________________________________________ _________________________________________________________________________ Filhos:_____________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________ Outros importantes:_________________________________________________________ __________________________________________________________________________________________________________________________________________________ Observações sobre dinâmica familiar atual:______________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Parte III – Infância Gravidez (planejada ou não), parto, intercorrências obstétricas:_______________________ __________________________________________________________________________________________________________________________________________________ Amamentação:______________________________________________________________________________________________________________________________________ Treinamento de Higiene:_____________________________________________________ __________________________________________________________________________________________________________________________________________________ Estressores na infância, crises:_________________________________________________ __________________________________________________________________________________________________________________________________________________ Outros transtornos infantis (sono, alimentação, psicomotor, gagueira, tiques, sonambulismo, aprendizagem):________________________________________________ __________________________________________________________________________________________________________________________________________________ Outros comentários:_________________________________________________________ __________________________________________________________________________________________________________________________________________________ Parte IV – Adolescência Experiências afetivas marcantes:_______________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________Experiências sexuais marcantes:_______________________________________________ __________________________________________________________________________________________________________________________________________________ Independência/ primeiros empregos:____________________________________________ __________________________________________________________________________________________________________________________________________________ Círculo de amizades:________________________________________________________ __________________________________________________________________________________________________________________________________________________ Parte V – Vida Adulta Relacionamento com parceiro:_________________________________________________ __________________________________________________________________________________________________________________________________________________ Vida Sexual Atual:__________________________________________________________ __________________________________________________________________________________________________________________________________________________ Situação Financeira:_________________________________________________________ _________________________________________________________________________ Abortos espontâneos/provocados:______________________________________________ Apoio Social disponível:_____________________________________________________ _________________________________________________________________________ Outros transtornos atuais (sono, alimentação, tiques,etc.):___________________________ _________________________________________________________________________ Principais lazeres, vida social:_________________________________________________ __________________________________________________________________________________________________________________________________________________ Parte VI – Observação e Linguagem Não verbal do Paciente Observações:________________________________________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________ Parte VII – Atendimentos Prestados Profissional:_______________________________________________________________ Encaminhamentos Feitos:____________________________________________________ __________________________________________________________________________________________________________________________________________________ Terapêutica Utilizada (prescrição de exercícios, leituras, relaxamento, etc.):_____________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________ Destino do caso: Alta ( ) Encaminhamento a outra instituição ( ) Qual ________________________________ Abandono ( ) Motivo___________________________________________________ Encaminhamento a outro profissional ( ) Quem ________________________________ Interrompido ( ) Por que__________________________________________________ Melhoras Obtidas:__________________________________________________________ __________________________________________________________________________________________________________________________________________________ �PAGE � �PAGE �1�
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