Anamnese adulto

Prévia do material em texto

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.):_____________
___________________________________________________________________________________________________________________________________________________________________________________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Data: __/__/__ Tema:______________________________________________________
Destino do caso:
Alta ( ) 
Encaminhamento a outra instituição ( ) Qual ________________________________
Abandono ( ) Motivo___________________________________________________
Encaminhamento a outro profissional ( ) Quem ________________________________
Interrompido ( ) Por que__________________________________________________
Melhoras Obtidas:__________________________________________________________
__________________________________________________________________________________________________________________________________________________
Outras Observações Importantes:______________________________________________
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
7