anamnese dos pais do acolhido

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Serviço de Acolhimento Institucional para Criança e Adolescente
Anamnese do adulto
Nome:_________________________________________________________________
Idade:_____________ Sexo:_______________ GÊNERO:______________________ 
Endereço:____________________________________________________________________________________________________________________________________
Telefones para Contato:__________________________________________________
Religião:___________________________Escolaridade:________________________
____________________________________________________________________
Profissão:______________________________________________________________
Est.Civil:___________________ 
Cônjuge (nome, idade e profissão):________________________________________________________
Expectativas e objetivos:____________________________________________________________________________________________________________________________________
Sintomas apresentados:______________________________________________________
_____________________________________________________________________________________
Parte I – iagnóstico
Eixo I:____________________________________________________________________
Eixo II (doenças físicas):______________________________________________________________
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Eixo III (estressores psicossociais):_____________________________________________
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Conceituação Psicológica do Caso:________________________________________________________________________________________________________________________________________ 
Transtornos psiquiátricos anteriores:____________________________________________
Transtornos psiquiátricos familiares:____________________________________________
Doenças Importantes que teve:____________________________________________
Medicação que está tomando:______________________________________________
Medicação alternativa (chás, compostos, etc.)_________________________________
Histórico da Queixa
Quando se iniciou:_________________________________________________________
____________________________________________________________________________________________________________________________________________
Eventos traumáticos de vida:
____________________________________________________________________________________________________________________________________________
Eventos/fatores que precipitam ou agravam crises:_______________________________________________________________________________________________________________________________________
Uso de drogas?_________________________________________________________
Tentativa de suicídio?_____________________________________________________
Parte II – Relacionamentos Importantes
Mãe:________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
Pai:_________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
Irmãos:______________________________________________________________________________________________________________________________________
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Filhos:_______________________________________________________________________________________________________________________________________
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Outros importantes:_________________________________________________________
____________________________________________________________________________________________________________________________________________
Observações sobre dinâmica familiar atual:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Parte III – Infância
Estressores na infância,crises:______________________________________________
______________________________________________________________________
______________________________________________________________________
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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:____________________________________________________
Destino do caso:
Alta ( ) 
Encaminhamento a outra instituição () Qual ________________________________
Abandono ( ) Motivo___________________________________________________
Encaminhamento a outro profissional ( ) Quem ________________________________
Interrompido ( ) Por que__________________________________________________
Melhoras Obtidas:__________________________________________________________
____________________________________________________________________________________________________________________________________________
Outras Observações Importantes:
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