Anamnese Completa Adulto

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Anamnese Completa Adulto
Nome:______________________________________________________________________ Idade:_____________ Sexo:_______________ CPF:_________________________________ Identidade:_______________________________ Endereço:________________________________________________________________________________________________________________________________________________ Telefones para Contato:_________________________________________________________ Bairro:____________________________ Cidade:____________________________________ Religião:___________________________ Escolaridade:_______________________________ Filhos (nome, idade e sexo)______________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Profissão:____________________________________________________________________ Est.Civil:_____________________________________________________________________ 
Cônjuge (nome, idade, profissão, escolaridade):______________________________________ ____________________________________________________________________________ Queixa principal:_______________________________________________________________ ________________________________________________________________________________________________________________________________________________________ Possibilidade de horários:_______________________________________________________ Fez terapia anteriormente? (citar qual e quando)_____________________________________ ____________________________________________________________________________ Expectativas e objetivos do paciente:______________________________________________ ________________________________________________________________________________________________________________________________________________________ Sintomas apresentados:_________________________________________________________ ________________________________________________________________________________________________________________________________________________________ Doenças físicas:_______________________________________________________________ ____________________________________________________________________________ Estressores psicossociais:_______________________________________________________ ____________________________________________________________________________ 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:_______________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
 Relacionamentos Importantes 
Conjuje:_____________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Mãe:____________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________ Pai:_____________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________ Irmãos:__________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________ Filhos:___________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________ Outros importantes:____________________________________________________________ ________________________________________________________________________________________________________________________________________________________ Observações sobre dinâmica familiar atual:_________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 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:____________________________________________________________ ________________________________________________________________________________________________________________________________________________________Adolescência Experiências afetivas marcantes:______________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Experiências sexuais marcantes:__________________________________________________ ________________________________________________________________________________________________________________________________________________________ Independência/ primeiros empregos:_______________________________________________ ________________________________________________________________________________________________________________________________________________________Círculo de amizades:___________________________________________________________ ________________________________________________________________________________________________________________________________________________________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:____________________________________________________ ________________________________________________________________________________________________________________________________________________________
Observação e Linguagem Não verbal do Paciente 
Observações:_________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________
 Atendimentos Prestados 
Profissional:__________________________________________________________________ Encaminhamentos Feitos:_______________________________________________________ ________________________________________________________________________________________________________________________________________________________ Terapêutica Utilizada (prescrição de exercícios, leituras, relaxamento, etc.):________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Layse Mello Batista
Psicóloga – CRP 05/64201
Tel.: (22) 981083558