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Anamnesea

Propaganda
Anamnese Completa do Adulto
Nome:____________________________________________________________________
Idade:_____________
Sexo:_______________
Endereço:_________________________________________________________________
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Telefones para Contato:______________________________________________________
Bairro:____________________________ Cidade:________________________________
Religião:___________________________ Escolaridade:___________________________
Filhos (nome, idade e sexo)___________________________________________________
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Profissão:_________________________________________________________________
Est.Civil:___________________
Cônjuge (nome, idade e profissão):_____________________________________________
Queixa principal:___________________________________________________________
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Possibilidade de horários:____________________________________________________
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 – Diagnóstico
Eixo I:____________________________________________________________________
Eixo II:___________________________________________________________________
Eixo III (doenças físicas):____________________________________________________
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Eixo IV (estressores psicossociais):_____________________________________________
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Eixo V (funcionamento global):________________________________________________
Conceituação Psicológica do Caso:_____________________________________________
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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:____________________________________
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Histórico da Queixa
Quando se iniciou:__________________________________________________________
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Eventos traumáticos de vida:__________________________________________________
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Eventos/fatores que precipitam ou agravam crises:_________________________________
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Uso de drogas?_____________________________________________________________
Tentativa de suicídio?_______________________________________________________
Focos de intervenção psicoterápica:_____________________________________________
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Parte II – Relacionamentos Importantes
Mãe:_____________________________________________________________________
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Pai:______________________________________________________________________
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Irmãos:___________________________________________________________________
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Filhos:____________________________________________________________________
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Outros importantes:_________________________________________________________
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Observações sobre dinâmica familiar atual:______________________________________
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Parte III – Infância
Gravidez (planejada ou não), parto, intercorrências obstétricas:_______________________
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Amamentação:_____________________________________________________________
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Treinamento de Higiene:_____________________________________________________
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Estressores na infância, crises:_________________________________________________
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Outros transtornos infantis (sono, alimentação, psicomotor, gagueira, tiques,
sonambulismo, aprendizagem):________________________________________________
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Outros comentários:_________________________________________________________
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Parte IV – Adolescência
Experiências afetivas marcantes:_______________________________________________
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Experiências sexuais marcantes:_______________________________________________
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Independência/ primeiros empregos:____________________________________________
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Círculo de amizades:________________________________________________________
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Parte V – Vida Adulta
Relacionamento com parceiro:_________________________________________________
_________________________________________________________________________
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Vida Sexual Atual:__________________________________________________________
_________________________________________________________________________
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Situação Financeira:_________________________________________________________
_________________________________________________________________________
Abortos espontâneos/provocados:______________________________________________
Apoio Social disponível:_____________________________________________________
_________________________________________________________________________
Outros transtornos atuais (sono, alimentação, tiques,etc.):___________________________
_________________________________________________________________________
Principais lazeres, vida social:_________________________________________________
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Parte VI – Observação e Linguagem Não verbal do Paciente
Observações:______________________________________________________________
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Parte VII – Atendimentos Prestados
Profissional:_______________________________________________________________
Encaminhamentos Feitos:____________________________________________________
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Terapêutica Utilizada (prescrição de exercícios, leituras, relaxamento, etc.):_____________
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Tema:______________________________________________________
Tema:______________________________________________________
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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:__________________________________________________________
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Outras Observações Importantes:______________________________________________
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