Anamnese Completa Adulto Paciente

Prévia do material em texto

Anamnese Adulto
Psicólogo – CRP 
	2021
Anamnese Completa Adulto
Nome:____________________________________________________________________
Idade:_____________ Sexo:_______________ 
CPF:____________________________ Identidade:_______________________________
Endereço:__________________________________________________________________________________________________________________________________________
Telefones para Contato:______________________________________________________
Bairro:____________________________ Cidade:________________________________
Religião:___________________________ Escolaridade:___________________________
Filhos (nome, idade e sexo) ___________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Profissão:_________________________________________________________________
Estado 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:_____________________________________________________
_________________________________________________________________________
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? _______________________________________________________
Relacionamentos Importantes
Cônjuge:__________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
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.):___________________________
_________________________________________________________________________
Lazer, vida social:_________________________________________________
__________________________________________________________________________________________________________________________________________________
Observação e Linguagem não verbal do Paciente
Observações:________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________