FICHA DE ANAMNESE

1. Caracterizao do Pedido
Data do pedido: ____/____/____
Quem vem entrevista: ____________________________________________________________________
Motivo da consulta: ________________________________________________________________________

2. Dados Biogrficos
Nome: ___________________________________________________________________________________
Data de nascimento: ____/____/____ Idade: __________
Estado Civil:____________________ Profisso:___________________________

3. Histria Familiar
Nome da me: ____________________________________________________________________________
Idade: __________ Profisso: _________________________
Como o cliente descreve a me:_____________________________________________________________
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Como foi o relacionamento, no passado, com a me?
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Como o actual relacionamento com a me?
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Nome do Pai: _____________________________________________________________________________

Idade: __________ Profisso: _________________________
Como o cliente descreve o pai:
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Como foi o relacionamento, no passado, com o pai?

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Como o actual relacionamento com o pai?
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Como era, no passado, e como , actualmente, o relacionamento entre o pai e a me?

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Nome e idades dos irmos:________________________________________________________________

4. Histria Profissional
Profisso Actual:__________________________________________________________________________
Qual o grau de satisfao com trabalho______________________________________________________

5. Histria Conjugal
Nmero de casamentos ou relaes:_________________________________________________________
Nome do cnjuge/companheiro: ___________________ Idade:_______ Profisso:____________________
Relacionamento, actual e passado com o cnjuge/companheiro: _______________________________
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Histria e caractersticas de relaes significativas anteriores: _________________________________
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Nome e idade dos filhos e Relacionamento com os filhos:____________________________________
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6. Estado de Sade
Principais doenas significativas do passado: _____________________________________________

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Estado de sade Actual: ____________________________________________
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Medicao Actual:_________________________________________________________________
Padres de Sono: ___________________________________________________________________
Padres de Alimentao e Bebida:____________________________________________________________

7. Preocupaes/Problema
Descrio do problema:
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H quanto tempo ele sentido? _____________________________________________________________
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O que j foi feito para o tentar resolver? _______________________________________________________
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Expectativas face consulta ________________________________________________________________
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8. Observaes finais
Comentrios sobre o comportamento durante a entrevista _______________________________________
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Opinies iniciais sobre a problemtica ________________________________________________________
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Informaes teis que escapam anamnese efectuada __________________________________________
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Data _______/_______/_______

O Psiclogo

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