ANAMNESE ADULTO

DADOS SOBRE O CLIENTE

- IDENTIFICAO
NOME___________________________________________________________IDADE________
NASC._____/______/_____SEXO_________________NATURALIDADE___________________EST.CIVIL_______
___________ESCOLARIDADE______________PROFISSO____________RELIGIO______________
PRATICANTE? SIM ( ) NO ( )
DADOS SOBRE A FAMLIA
CNJUGE______________________________________________________IDADE__________
PROFISSO______________NATURALIDADE____________ESCOLARIDADE____________
FILHOS (SEXO)___________________________________IDADE_________________________
NOME DO PAI_____________________________________IDADE________________________
PROFISSO___________NATURALIDADE_____________ESCOLARIDADE______________
NOME DA ME________________________________________IDADE___________________
PROFISSO________________NATURALIDADE____________ESCOLARIDADE__________
IRMOS_______________________POSIO DE NASCIMENTO _______________________
ENDEREO RESIDENCIAL________________________________________________________
CELULAR _________________________TEL. RESIDENCIAL_______________
CONDIOES SCIO-ECONMICAS RENDA FAMILIAR At 1 salrio mnimo ( ) De 1 a 2 salrios mnimos ( )
De 2 a 3 salrios mnimos ( ) De 3 a 5 salrios mnimos ( ) De 5 a 10 salrios mnimos ( ) De 10 a 20 salrios mnimos
( ) Mais de 20 salrios mnimos.
QUANTAS
PESSOAS
TRABALHAM
NA
FAMLIA______QUAIS?__________________
________________________________________________N DE DEPENDENTES____________
A FAMLIA RESIDE EM:
CASA
APARTAMENTO
( ) Prpria
( ) Quitado
( ) Alugada
( ) Financiado
( ) Cedido
( ) Outro
CONSULTA PSICOLGICA ANTERIORMENTE? SIM ( ) NO ( )
CONSULTA PSIQUITRICA ANTERIORMENTE? SIM ( ) NO ( )
ENCAMINHADO:________________________________________________________________
MOTIVO DA PROCURA DOS SERVIOS.
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- HISTRICO DAS DIFICULDADES RELATADAS (desde quando apresenta a queixa)
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OPERACIONALIZAO DA QUEIXA
H quanto tempo voc (sr./sra.) apresenta este comportamento? _______________________
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Como este comportamento se manifestou primeiramente? Como ele se iniciou?
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Em quais circunstncias acontece? O que acontece antes do comportamento se manifestar?
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Qual sua freqncia? (a que horas acontece / em que local / durao)

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Qual a ltima vez que este comportamento aconteceu?
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Voc j tomou alguma providncia quanto a este comportamento? O que foi feito para resolver o problema?
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O que acontece logo aps a manifestao deste comportamento?
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Quais as conseqncias deste comportamento?
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Voc tinha muitas regras quando criana? Como foi sua infncia?
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- MEDOS
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- AGRESSIVIDADE
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- SONO
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- DINMICA FAMILIAR (considerar as famlias nuclear e constituda)
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- DINMICA DO RELACIONAMENTO SOCIAL
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- DINMICA PROFISSIONAL
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- SADE
a) PESSOAL
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b) FAMILIAR
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- ASPECTOS SIGNIFICATIVOS PERCEBIDOS DURANTE A ENTREVISTA

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- PARECER DIAGNSTICO Sintomatologia relatada, relacionada com a Psicodinmica do cliente
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- ORIENTAO TERAPUTICA (ENCAMINHAMENTOS)
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Teresina, PI____/____/_____