ANAMNESE

ENTREVISTA PARA AVALIAO PSICOLGICA

01- DADOS DE IDENTIFICAO:

Nome:
Data de Nascimento:
Religio:
Curso: Centro:
Perodo:
Matrcula:
Contato:
Encaminhado por:
ENCAMINHAMENTO:
PROFISSIONAL RESPONSVEL:

Idade:
Protocolo:

02- DADOS DE INDENTIFICAO DOS PAIS:

Nome Pai:
Profisso:
Grau de instruo:
Nome Me:
Profisso:
Grau de instruo:
Endereo:
Telefone:
Estado civil:

Idade:
Empresa:
Idade:
Empresa:
E-mail:

03- QUEIXA PRINCIPAL:

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04- EVOLUO DA QUEIXA:

-Incio da queixa:______________________________________________________________________
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- Sbita ou progressiva:_________________________________________________________________
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- Quais as mudanas que ocorreram/ o que afetou:____________________________________________
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- Sintomas:___________________________________________________________________________
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05- QUEIXAS SECUNDRIAS:

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06- HISTRIA CLNICA:

-Doena crnica:_______________________________________________________________________
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-Uso de medicamentos? Se sim, quais:______________________________________________________
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-Casos de internao:___________________________________________________________________
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-Enfrentamento: _______________________________________________________________________
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-Sintomas fsicos e/ou psicolgicos:________________________________________________________
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- Psicoterapia/fono/fisio/neuro/psiquiatria:
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- Hbitos Alimentares:__________________________________________________________________
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Para crianas ou adolescentes:
- Condies de Nascimento:______________________________________________________________
- Desenvolvimento Neuropsicomotor:______________________________________________________
- Doenas infantis:_____________________________________________________________________
- Casos de convulses,epilepsia,desmaios etc:________________________________________________
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07- HISTRIA FAMILIAR:

Composio Familiar:___________________________________________________________________
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Dinmica Familiar:____________________________________________________________________
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- Eventos Significativos:________________________________________________________________
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-Rede de Apoio:_______________________________________________________________________

08- HISTRIA SOCIAL:

- Vida Social: _________________________________________________________________________
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- Hbitos de lazer: _____________________________________________________________________
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- Rede de Apoio: ______________________________________________________________________

09- DADOS ESCOLARES:

- Casos de reprovao:__________________________________________________________________
- reas de dificuldade:__________________________________________________________________
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- Hbitos de Estudo:____________________________________________________________________

10- CONSIDERAES FINAIS::

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11- SUGESTO DE ENCAMINHAMENTO:

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Assinatura do profissional