89413601 2-roteiro-de-entrevista-anamnese-para-avaliacao-psicologica-l-130927064916-phpapp01
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Transcript of 89413601 2-roteiro-de-entrevista-anamnese-para-avaliacao-psicologica-l-130927064916-phpapp01
ANAMNESER O T E I R O D E E N T R E V I S T A P A R A A V A L I A Ç Ã O P S I C O L Ó G I C A
01- DADOS DE IDENTIFICAÇÃO:Nome: Data de Nascimento: Idade: Religião: Curso: Centro: Período: Matrícula: Protocolo:Contato: Encaminhado por: ENCAMINHAMENTO:PROFISSIONAL RESPONSÁVEL:
02- DADOS DE INDENTIFICAÇÃO DOS PAIS:Nome Pai: Idade:Profissão: Empresa: Grau de instrução:Nome Mãe: Idade:Profissão: Empresa: Grau de instrução:Endereço:Telefone: E-mailEstado civil:
03- QUEIXA PRINCIPAL:
04- EVOLUÇÃO DA QUEIXA:-Início da queixa:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________- Súbita ou progressiva:_____________________________________________________________________________________________________________________________________________________
- Quais as mudanças que ocorreram/ o que afetou:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
- Sintomas:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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05- QUEIXAS SECUNDÁRIAS:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
06- HISTÓRIA CLÍNICA:-Doença crônica: -_____________________________________________________________________________________-Uso de medicamentos. Quais:
_____________________________________________________________________________________-Casos de internação: _____________________________________________________________________________________-Enfrentamento: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________-Sintomas físicos e/ou psicológicos:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________- Psicoterapia/fono/fisio/neuro/psiquiatria: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________- Hábitos Alimentares:
Para crianças ou adolescentes:- Condições de Nascimento:
- Desenvolvimento Neuropsicomotor: - Doenças infantis: - Casos de convulsões,epilepsia,desmaios etc: -
07- HISTÓRIA FAMILIAR:Composição Familiar: (genotograma)
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-Dinâmica Familiar:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________- Eventos Significativos:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________-Rede de Apoio:
08- HISTÓRIA SOCIAL:- Vida Social: - Hábitos de lazer: - Inserção em Grupos: - Rede de Apoio:
09- DADOS ESCOLARES:- Casos de reprovação:
- Áreas de dificuldade: _____________________________________________________________________________________- Hábitos de Estudo:.
10- CONSIDERAÇÕES FINAIS::________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
11- SUGESTÃO DE ENCAMINHAMENTO:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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__________________________________________________________________________________
_____________________________________Assinatura do profissional
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