Anamnese Completa Adulto Paciente PDF

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BEM VIVER PSICOLOGIA CLÍNICA

2018

CNPJ: 24.474.328/0001-08 Walace Rodrigues – Psicólogo CRP 04/44639

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:______________________________________________________ ________________________________________________________________________________ __________________________________________________________________

Rua João da Silva Araújo, nº 05 Apto 101 – CEP: 35.300-238 Telefone: (33) 3322-3551 – Celular: (33) 98842-3003 WhatsApp CARATINGA – MINAS GERAIS Página 1

BEM VIVER PSICOLOGIA CLÍNICA

2018

CNPJ: 24.474.328/0001-08 Walace Rodrigues – Psicólogo CRP 04/44639 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:__________________________________________________

Rua João da Silva Araújo, nº 05 Apto 101 – CEP: 35.300-238 Telefone: (33) 3322-3551 – Celular: (33) 98842-3003 WhatsApp CARATINGA – MINAS GERAIS Página 2

BEM VIVER PSICOLOGIA CLÍNICA

2018

CNPJ: 24.474.328/0001-08 Walace Rodrigues – Psicólogo CRP 04/44639 ________________________________________________________________________________ __________________________________________________________________ Eventos/fatores que precipitam ou agravam crises:_________________________________ _________________________________________________________________________

Uso de drogas?_____________________________________________________________ Tentativa de suicídio?_______________________________________________________ Focos de intervenção psicoterápica:_____________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ___________________________________________________________

Relacionamentos Importantes

Conjuje:__________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________

Mãe:____________________________________________________________________________ __________________________________________________________________ ________________________________________________________________________________ __________________________________________________________________ Pai:_____________________________________________________________________________ __________________________________________________________________ ________________________________________________________________________________ __________________________________________________________________ Irmãos:__________________________________________________________________________ __________________________________________________________________ _________________________________________________________________________

Rua João da Silva Araújo, nº 05 Apto 101 – CEP: 35.300-238 Telefone: (33) 3322-3551 – Celular: (33) 98842-3003 WhatsApp CARATINGA – MINAS GERAIS Página 3

BEM VIVER PSICOLOGIA CLÍNICA

2018

CNPJ: 24.474.328/0001-08 Walace Rodrigues – Psicólogo CRP 04/44639 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):________________________________________________

Rua João da Silva Araújo, nº 05 Apto 101 – CEP: 35.300-238 Telefone: (33) 3322-3551 – Celular: (33) 98842-3003 WhatsApp CARATINGA – MINAS GERAIS Página 4

BEM VIVER PSICOLOGIA CLÍNICA

2018

CNPJ: 24.474.328/0001-08 Walace Rodrigues – Psicólogo CRP 04/44639 ________________________________________________________________________________ __________________________________________________________________ Outros comentários:_________________________________________________________ ________________________________________________________________________________ __________________________________________________________________

Adolescência

Experiências afetivas marcantes:_______________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ___________________________________________________________ Experiências sexuais marcantes:_______________________________________________ ________________________________________________________________________________ __________________________________________________________________ Independência/ primeiros empregos:____________________________________________ ________________________________________________________________________________ __________________________________________________________________ Círculo de amizades:________________________________________________________ ________________________________________________________________________________ __________________________________________________________________

Vida Adulta

Relacionamento com parceiro:_________________________________________________ ________________________________________________________________________________ __________________________________________________________________ Vida Sexual Atual:__________________________________________________________

Rua João da Silva Araújo, nº 05 Apto 101 – CEP: 35.300-238 Telefone: (33) 3322-3551 – Celular: (33) 98842-3003 WhatsApp CARATINGA – MINAS GERAIS Página 5

BEM VIVER PSICOLOGIA CLÍNICA

2018

CNPJ: 24.474.328/0001-08 Walace Rodrigues – Psicólogo CRP 04/44639 ________________________________________________________________________________ __________________________________________________________________ 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.):_____________ Rua João da Silva Araújo, nº 05 Apto 101 – CEP: 35.300-238 Telefone: (33) 3322-3551 – Celular: (33) 98842-3003 WhatsApp CARATINGA – MINAS GERAIS Página 6

BEM VIVER PSICOLOGIA CLÍNICA

2018

CNPJ: 24.474.328/0001-08 Walace Rodrigues – Psicólogo CRP 04/44639 ________________________________________________________________________________ ________________________________________________________________________________ ___________________________________________________________

Rua João da Silva Araújo, nº 05 Apto 101 – CEP: 35.300-238 Telefone: (33) 3322-3551 – Celular: (33) 98842-3003 WhatsApp CARATINGA – MINAS GERAIS Página 7...