Anamnese Completa do Adulto Nome:____________________________________________________________________ Idade:_____________ Sexo:_______________ Endereço:_________________________________________________________________ _________________________________________________________________________ Telefones para Contato:______________________________________________________ Bairro:____________________________ Cidade:________________________________ Religião:___________________________ Escolaridade:___________________________ Filhos (nome, idade e sexo)___________________________________________________ _________________________________________________________________________ Profissão:_________________________________________________________________ Est.Civil:___________________ Cônjuge (nome, idade e profissão):_____________________________________________ Queixa principal:___________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Possibilidade de horários:____________________________________________________ Fez terapia anteriormente? (citar qual e quando)___________________________________ _________________________________________________________________________ Expectativas e objetivos do paciente:___________________________________________ _________________________________________________________________________ _________________________________________________________________________ Sintomas apresentados:______________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Parte I – Diagnóstico Eixo I:____________________________________________________________________ Eixo II:___________________________________________________________________ Eixo III (doenças físicas):____________________________________________________ _________________________________________________________________________ Eixo IV (estressores psicossociais):_____________________________________________ _________________________________________________________________________ Eixo V (funcionamento global):________________________________________________ Conceituação Psicológica do Caso:_____________________________________________ _________________________________________________________________________ _________________________________________________________________________ Transtornos psiquiátricos anteriores:____________________________________________ Transtornos psiquiátricos familiares:____________________________________________ Doenças Importantes que teve:________________________________________________ 1 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:_____________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Parte II – Relacionamentos Importantes Mãe:_____________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Pai:______________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Irmãos:___________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Filhos:____________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Outros importantes:_________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Observações sobre dinâmica familiar atual:______________________________________ 2 _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Parte III – 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:_________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Parte IV – Adolescência Experiências afetivas marcantes:_______________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Experiências sexuais marcantes:_______________________________________________ _________________________________________________________________________ _________________________________________________________________________ Independência/ primeiros empregos:____________________________________________ _________________________________________________________________________ _________________________________________________________________________ Círculo de amizades:________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Parte V – Vida Adulta Relacionamento com parceiro:_________________________________________________ _________________________________________________________________________ _________________________________________________________________________ 3 Vida Sexual Atual:__________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Situação Financeira:_________________________________________________________ _________________________________________________________________________ Abortos espontâneos/provocados:______________________________________________ Apoio Social disponível:_____________________________________________________ _________________________________________________________________________ Outros transtornos atuais (sono, alimentação, tiques,etc.):___________________________ _________________________________________________________________________ Principais lazeres, vida social:_________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Parte VI – Observação e Linguagem Não verbal do Paciente Observações:______________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Parte VII – Atendimentos Prestados Profissional:_______________________________________________________________ Encaminhamentos Feitos:____________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Terapêutica Utilizada (prescrição de exercícios, leituras, relaxamento, etc.):_____________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ 4 Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Data: __/__/__ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Tema:______________________________________________________ Destino do caso: Alta ( ) Encaminhamento a outra instituição ( ) Qual ________________________________ Abandono ( ) Motivo___________________________________________________ Encaminhamento a outro profissional ( ) Quem ________________________________ Interrompido ( ) Por que__________________________________________________ Melhoras Obtidas:__________________________________________________________ 5 _________________________________________________________________________ _________________________________________________________________________ Outras Observações Importantes:______________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ 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