Rebeca S.
I Gomes Psicóloga CRP-05/57106
Atendimento adulto adolescente e infantil
conteú do confidencial
ANAMNESE
01- DADOS DE IDENTIFICAÇÃO:
Nome:
Data de Nascimento: Idade:
Religião:
Contato:
Encaminhado por:
ENCAMINHAMENTO:
PROFISSIONAL RESPONSÁVEL:
02-QUEIXA PRINCIPAL:
____________________________________________________________________________________
____________________________________________________________________________________
03- EVOLUÇÃO DA QUEIXA:
-Início da queixa:______________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
- Súbita ou progressiva:_________________________________________________________________
____________________________________________________________________________________
- Quais as mudanças que ocorreram/ o que afetou:____________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
- Sintomas:___________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
04- QUEIXAS SECUNDÁRIAS:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
05- HISTÓRIA CLÍNICA:
-Doença crônica:_______________________________________________________________________
_____________________________________________________________________________________
-Uso de medicamentos? Se sim, quais:______________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
-Casos de internação:___________________________________________________________________
_____________________________________________________________________________________
-Enfrentamento: _______________________________________________________________________
_____________________________________________________________________________________
-Sintomas físicos e/ou psicológicos:________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
- Psicoterapia/fono/fisio/neuro/psiquiatria:
________________________________________________________________________________________
__________________________________________________________________________________
_____________________________________________________________________________________
- Hábitos Alimentares:__________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Históricos de doenças:
06- HISTÓRIA FAMILIAR:
Composição Familiar:___________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Dinâmica Familiar:____________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
- Eventos Significativos:________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
-Rede de Apoio:_______________________________________________________________________
07- HISTÓRIA SOCIAL:
- Vida Social: _________________________________________________________________________
_____________________________________________________________________________________
- Hábitos de lazer: _____________________________________________________________________
_____________________________________________________________________________________
- Rede de Apoio: ______________________________________________________________________
OBS( eventos significativos,dados relevantes para o paciente):
_____________________________________
Rebeca dos santos Ivantes Gomes