A Anamnese Completa Adulto

Anamnese Completa Adulto Nome:____________________________________________________________________ Idade:_____________ Sexo:_______________ CPF:____________________________ Identidade:_______________________________ Endereço:__________________________________________________________________________________________________________________________________________ Telefones para Contato:______________________________________________________ Bairro:____________________________ Cidade:________________________________ Religião:___________________________ Escolaridade:___________________________ Filhos (nome, idade e sexo)___________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Profissão:_________________________________________________________________ Est.Civil:___________________ Cônjuge (nome, idade, profissão, escolaridade):__________________________________ _________________________________________________________________________ Queixa principal:___________________________________________________________ __________________________________________________________________________________________________________________________________________________ Possibilidade de horários:____________________________________________________ Fez terapia anteriormente? (citar qual e quando)___________________________________ _________________________________________________________________________ Expectativas e objetivos do paciente:___________________________________________ __________________________________________________________________________________________________________________________________________________ Sintomas apresentados:______________________________________________________ __________________________________________________________________________________________________________________________________________________ Doenças físicas:____________________________________________________________ _________________________________________________________________________ Estressores psicossociais:_____________________________________________________ _________________________________________________________________________ Funcionamento global:_______________________________________________________ Conceituação Psicológica do Caso:_____________________________________________ __________________________________________________________________________________________________________________________________________________ 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:____________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________ 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:_____________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________ Relacionamentos Importantes Conjuje:__________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Mãe:______________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________ Pai:_______________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________ Irmãos:____________________________________________________________________________________________________________________________________________ _________________________________________________________________________ Filhos:_____________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________ Outros importantes:_________________________________________________________ __________________________________________________________________________________________________________________________________________________ Observações sobre dinâmica familiar atual:______________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 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:_________________________________________________________ __________________________________________________________________________________________________________________________________________________ Adolescência Experiências afetivas marcantes:_______________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________ Experiências sexuais marcantes:_______________________________________________ __________________________________________________________________________________________________________________________________________________ Independência/ primeiros empregos:____________________________________________ __________________________________________________________________________________________________________________________________________________ Círculo de amizades:________________________________________________________ __________________________________________________________________________________________________________________________________________________ Vida Adulta Relacionamento com parceiro:_________________________________________________ __________________________________________________________________________________________________________________________________________________ Vida Sexual Atual:__________________________________________________________ __________________________________________________________________________________________________________________________________________________ Situação Financeira:_________________________________________________________ _________________________________________________________________________ Abortos espontâneos/provocados:______________________________________________ Apoio Social disponível:_____________________________________________________ _________________________________________________________________________ Outros transtornos atuais (sono, alimentação, tiques,etc.):___________________________ _________________________________________________________________________ Principais lazeres, vida social:_________________________________________________ __________________________________________________________________________________________________________________________________________________ Observação e Linguagem Não verbal do Paciente Observações:________________________________________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________ Atendimentos Prestados Profissional:_______________________________________________________________ Encaminhamentos Feitos:____________________________________________________ __________________________________________________________________________________________________________________________________________________ Terapêutica Utilizada (prescrição de exercícios, leituras, relaxamento, etc.):_____________ 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