anamnese adulto

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ANAMNESE COMPLETA ADULTO 
(Nome da Clínica ou Folha Timbrada) 
Estado, XX de xxxxxxxx de XXXX. 
 
 
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:___________________________________________ 
________________________________________________________________________________
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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:___________________________________________________ 
________________________________________________________________________________
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Parte II – Relacionamentos Importantes 
 
Mãe:____________________________________________________________________________
________________________________________________________________________________ 
________________________________________________________________________________
________________________________________________________________________________ 
Pai:_____________________________________________________________________________
________________________________________________________________________________ 
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Irmãos:__________________________________________________________________________
________________________________________________________________________________ 
________________________________________________________________________________ 
Filhos:__________________________________________________________________________
________________________________________________________________________________ 
 
 
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Outros importantes:________________________________________________________________ 
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Observações sobre dinâmica familiar atual:_____________________________________________ 
________________________________________________________________________________
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Parte III – Infância 
 
Gravidez (planejada ou não), parto, intercorrências obstétricas:______________________________ 
________________________________________________________________________________
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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:______________________________________________________ 
________________________________________________________________________________
________________________________________________________________________________
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Experiências sexuais marcantes:______________________________________________________ 
________________________________________________________________________________
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Independência/ primeiros empregos:___________________________________________________ 
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Círculo de amizades:_______________________________________________________________ 
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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.):___________________ 
________________________________________________________________________________
________________________________________________________________________________
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Destino do caso: 
Alta ( ) 
Encaminhamento a outra instituição ( ) Qual __________________________________________ 
Abandono ( ) Motivo_____________________________________________________________ 
Encaminhamento a outro profissional ( ) Quem _________________________________________ 
Interrompido ( ) Por que___________________________________________________________ 
 
 
 
Melhoras Obtidas:_________________________________________________________________ 
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Outras Observações Importantes:_____________________________________________________________________________________________________________________________________
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Responsável 
 
 
 
 
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Psicóloga(o) 
Nº de inscrição no CRP