Anamnese Completa do Adulto

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Anamnese Completa do Adu lto 
Nome:____________________________________________________________________ 
Idade:_____________ Sexo:_______________ 
Endereço:_________________________________________________________________ 
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Telefones para Contato:______________________________________________________ 
Bairro:____________________________ Cidade:________________________________ 
Religião:___________________________ Escolaridade:___________________________ 
Filhos (nome, idade e sexo)___________________________________________________ 
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Profissão:_________________________________________________________________ 
Est.Civil:___________________ 
Cônjuge (nome, idade e profissão):_____________________________________________ 
Queixa principal:___________________________________________________________ 
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Possibilidade de horários:____________________________________________________ 
Fez terapia anteriormente? (citar qual e quando)___________________________________ 
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Expectativas e objetivos do paciente:___________________________________________ 
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Sintomas apresentados:______________________________________________________ 
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Parte I – Diagnóstico 
Eixo I:____________________________________________________________________ 
Eixo II:___________________________________________________________________ 
Eixo III (doenças físicas):____________________________________________________ 
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Eixo IV (estressores psicossociais):_____________________________________________ 
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Eixo V (funcionamento global):________________________________________________ 
Conceituação Psicológica do Caso:_____________________________________________ 
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Transtornos psiquiátricos anteriores:____________________________________________ 
Transtornos psiquiátricos familiares:____________________________________________ 
Doenças Importantes que teve:________________________________________________ 
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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:__________________________________________________________ 
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Eventos traumáticos de vida:__________________________________________________ 
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Eventos/fatores que precipitam ou agravam crises:______________________ ___________ 
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Uso de drogas?_____________________________________________________________ 
Tentativa de suicídio?_______________________________________________________ 
Focos de intervenção psicoterápica:_____________________________________________ 
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Parte II – Relacionamentos Importantes 
Mãe:_____________________________________________________________________ 
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Pai:______________________________________________________________________ 
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Irmãos:___________________________________________________________________ 
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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:_____________________________________________________________ 
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Treinamento de Higiene:_____________________________________________________ 
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Estressores na infância, crises:_________________________________________________ 
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Outros transtornos infantis (sono, alimentação, psicomotor, gagueira, tiques, 
sonambulismo, aprendizagem):________________________________________________ 
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Outros comentários:_________________________________________________________ 
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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:_________________________________________________ 
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Vida Sexual Atual:__________________________________________________________ 
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Situação Financeira:_________________________________________________________ 
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Abortos espontâneos/provocados:______________________________________________ 
Apoio Social disponível:_____________________________________________________ 
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Outros transtornos atuais (sono, alimentação, tiques,etc.):___________________________ 
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Principais lazeres, vida social:_________________________________________________ 
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Parte VI – Observação e Linguagem Não verbal do Paciente 
Observações:______________________________________________________________ 
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Parte VII – Atendimentos Prestados 
Profissional:_______________________________________________________________ 
Encaminhamentos Feitos:____________________________________________________ 
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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:_________________________________________________________