EVERALDO DE CARVALHO 2022

CPF: 278.395.308-00
Psicó logo CRP 06/90100

Anamnese Completa Adulto

Nome:____________________________________________________________________
Idade:_____________Sexo:______________CPF:________________________________
Identidade:_________________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, profissão, escolaridade):__________________________________
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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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 EVERALDO DE CARVALHO 2022
CPF: 278.395.308-00
Psicó logo CRP 06/90100

Doenças físicas:____________________________________________________________
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Estressores psicossociais:_____________________________________________________
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Funcionamento global:_______________________________________________________

Conceituação Psicológica do Caso:_____________________________________________

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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:____________________________________

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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:_________________________________
 EVERALDO DE CARVALHO 2022
CPF: 278.395.308-00
Psicó logo CRP 06/90100

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Uso de drogas?_____________________________________________________________
Tentativa de suicídio?_______________________________________________________
Focos de intervenção psicoterápica:_____________________________________________
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Relacionamentos Importantes

Conjuje:__________________________________________________________________
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Mãe:_____________________________________________________________________________
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Pai:______________________________________________________________________________
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Irmãos:___________________________________________________________________________
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Filhos:____________________________________________________________________________
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Outros importantes:_________________________________________________________
 EVERALDO DE CARVALHO 2022
CPF: 278.395.308-00
Psicó logo CRP 06/90100

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Observações sobre dinâmica familiar atual:______________________________________

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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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Adolescência
 EVERALDO DE CARVALHO 2022
CPF: 278.395.308-00
Psicó logo CRP 06/90100

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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Vida Adulta

Relacionamento com parceiro:_________________________________________________

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Vida Sexual Atual:__________________________________________________________
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Situação Financeira:_________________________________________________________
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Abortos espontâneos/provocados:______________________________________________

Apoio Social disponível:_____________________________________________________

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Outros transtornos atuais (sono, alimentação, tiques,etc.):___________________________
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Principais lazeres, vida social:_________________________________________________
 EVERALDO DE CARVALHO 2022
CPF: 278.395.308-00
Psicó logo CRP 06/90100

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Observação e Linguagem Não verbal do Paciente

Observações:______________________________________________________________________
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Atendimentos Prestados

Profissional:_______________________________________________________________

Encaminhamentos Feitos:____________________________________________________
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Terapêutica Utilizada (prescrição de exercícios, leituras, relaxamento, etc.):_____________
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