Anamnese Completa do Adulto

Anamnese Completa do AdultoNome:____________________________________________________________________

Idade:_____________ Sexo:_______________

Endereo:__________________________________________________________________________________________________________________________________________

Telefones para Contato:______________________________________________________

Bairro:____________________________ Cidade:________________________________

Religio:___________________________ Escolaridade:___________________________

Filhos (nome, idade e sexo)___________________________________________________

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Profisso:_________________________________________________________________

Est.Civil:___________________

Cnjuge (nome, idade e profisso):_____________________________________________

Queixa principal:___________________________________________________________

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Possibilidade de horrios:____________________________________________________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 Diagnstico

Eixo I:____________________________________________________________________

Eixo II:___________________________________________________________________

Eixo III (doenas fsicas):____________________________________________________

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Eixo IV (estressores psicossociais):_____________________________________________

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Eixo V (funcionamento global):________________________________________________

Conceituao Psicolgica do Caso:_____________________________________________

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Transtornos psiquitricos anteriores:____________________________________________

Transtornos psiquitricos familiares:____________________________________________

Doenas Importantes que teve:________________________________________________

Medicao que est tomando:_________________________________________________

Medicao alternativa (chs, compostos, etc.)_____________________________________

Aplicao de Testes? Se sim, qual e resultado:____________________________________

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Histrico da QueixaQuando se iniciou:__________________________________________________________

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Eventos traumticos de vida:__________________________________________________

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Eventos/fatores que precipitam ou agravam crises:_________________________________

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Uso de drogas?_____________________________________________________________

Tentativa de suicdio?_______________________________________________________

Focos de interveno psicoterpica:_____________________________________________

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Parte II Relacionamentos Importantes

Me:______________________________________________________________________________________________________________________________________________

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Pai:_______________________________________________________________________________________________________________________________________________

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Irmos:____________________________________________________________________________________________________________________________________________

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Filhos:_____________________________________________________________________________________________________________________________________________

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Outros importantes:_________________________________________________________

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Observaes sobre dinmica familiar atual:______________________________________

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Parte III Infncia

Gravidez (planejada ou no), parto, intercorrncias obsttricas:_______________________

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Amamentao:______________________________________________________________________________________________________________________________________

Treinamento de Higiene:_____________________________________________________

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Estressores na infncia, crises:_________________________________________________

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Outros transtornos infantis (sono, alimentao, psicomotor, gagueira, tiques, sonambulismo, aprendizagem):________________________________________________

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Outros comentrios:_________________________________________________________

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Parte IV Adolescncia

Experincias afetivas marcantes:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Experincias sexuais marcantes:_______________________________________________

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Independncia/ primeiros empregos:____________________________________________

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Crculo de amizades:________________________________________________________

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Parte V Vida Adulta

Relacionamento com parceiro:_________________________________________________

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Vida Sexual Atual:__________________________________________________________

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Situao Financeira:_________________________________________________________

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Abortos espontneos/provocados:______________________________________________

Apoio Social disponvel:_____________________________________________________

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Outros transtornos atuais (sono, alimentao, tiques,etc.):___________________________

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Principais lazeres, vida social:_________________________________________________

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Parte VI Observao e Linguagem No verbal do Paciente

Observaes:________________________________________________________________________________________________________________________________________________________________________________________________________________

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Parte VII Atendimentos Prestados

Profissional:_______________________________________________________________

Encaminhamentos Feitos:____________________________________________________

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Teraputica Utilizada (prescrio de exerccios, leituras, relaxamento, etc.):_____________

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Destino do caso:

Alta ( )

Encaminhamento a outra instituio ( ) Qual ________________________________Abandono ( ) Motivo___________________________________________________Encaminhamento a outro profissional ( ) Quem ________________________________Interrompido ( ) Por que__________________________________________________Melhoras Obtidas:__________________________________________________________

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Outras Observaes Importantes:______________________________________________

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