Centro de Sade da Sobreira

Servio de Psicologia Clnica

Histria Clnica

Data: ___/___/___

N do Processo: __________

DADOS DE IDENTIFICAO:

Nome: _______________________________________________________

Idade: ______ Data de Nascimento: ___/___/___

Estado Civil _________________

Naturalidade______________________ Residncia _________________

Telefone ______________ Telemvel ________________

Profisso: _____________________________________________________

Nvel Scio-Econmico____________________________

Agregado familiar_____________________________

Observaes:
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MOTIVOS DO ENCAMINHAMENTO E DA CONSULTA:

Motivo do Encaminhamento_________________________________________________
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Motivo da Consulta: _______________________________________________________

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HISTRIA da DOENA ACTUAL (inclui relao biogrfica)

Queixas_________________________________________________________________
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Levantamento da Sintomatologia (emergncia, evoluo e comportamentos

consequentes)____________________________________________________________
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Porqu agora?____________________________________________________________
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Pedidos anteriores de ajuda para o problema____________________________________

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DADOS ACTUAIS

Interesses________________________________________________________________
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Redes Sociais (suportes) ___________________________________________________

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Ocupao profissional e Tempos livres________________________________________

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 OBSERVAO

DESCRIO GERAL DO PACIENTE

Aparncia geral: __________________________________________________________

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Atitude perante o psiclogo: ________________________________________________

Contacto Ocular: _________________________________________________________

Expresso facial: _________________________________________________________

Excitao emocional (lgrimas, engolir saliva, sudao,etc):_______________________

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Conduta e actividade psicomotora: ___________________________________________

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Postura (relaxada, tensa): _________________________________________________

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Linguagem: _____________________________________________________________
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Impresses causadas no psiclogo: ___________________________________________

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EXPLORAO PSICOPATOLGICA:

Discurso________________________________________________________________
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Pensamento (forma e contedo)______________________________________________

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Estado de conscincia______________________________________________________
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Memria________________________________________________________________
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Ateno_________________________________________________________________
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Raciocnio e juzo crtico___________________________________________________

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Inteligncia______________________________________________________________
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Vontade_________________________________________________________________
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Afectividade_____________________________________________________________
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Humor__________________________________________________________________
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Percepo_______________________________________________________________
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Perturbaes de carcter obsessivo, fbico ou compulsivo _________________________

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 RELATRIO DA 1 CONSULTA

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HISTRIA E DINMICA FAMILIAR

Genograma

Habitao e contexto familiar________________________________________________

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Histria Familiar

Me:

Nome___________________________________________________________________

Idade_________ Habilitaes Literrias______________ Profisso________________

Como descrita pelo paciente_______________________________________________

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Relao com o paciente____________________________________________________

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Estilo Educativo__________________________________________________________
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Antecedentes Psicopatolgicos_______________________________________________
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Pai:

Nome___________________________________________________________________

Idade_________ Habilitaes Literrias______________ Profisso________________

Como descrito pelo paciente_______________________________________________

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Relao com o paciente____________________________________________________

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Estilo Educativo__________________________________________________________
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Antecedentes Psicopatolgicos_______________________________________________
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Irmos:

Nomes__________________________________________________________________
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Idade_________ Habilitaes Literrias______________ Profisso________________

Idade_________ Habilitaes Literrias______________ Profisso________________

Idade_________ Habilitaes Literrias______________ Profisso________________

Idade_________ Habilitaes Literrias______________ Profisso________________

Como so descritos pelo paciente_____________________________________________

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Relao com o paciente____________________________________________________

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Antecedentes Psicopatolgicos_______________________________________________
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Outras figuras significativas_________________________________________________

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Idades quando nasceu o paciente_____________________________________________

Relacionamento com o paciente______________________________________________

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Relacionamento Pai-Me___________________________________________________
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Relacionamento Pais-Irmos________________________________________________
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Ambiente familiar_________________________________________________________
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Educao (regras/limites)___________________________________________________
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Tempo e Actividades conjuntas______________________________________________

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Pessoas com quem viveu ao longo do tempo____________________________________

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Observaes_____________________________________________________________
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ANTECEDENTES PESSOAIS

Contexto Familiar_________________________________________________________
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Gravidez________________________________________________________________
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Parto___________________________________________________________________
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Perodo Neo-natal_________________________________________________________
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Alimentao_____________________________________________________________
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Desenvolvimento Psicomotor________________________________________________
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Perodo Pr-escolar________________________________________________________
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Vida Escolar_____________________________________________________________
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Profisso e Trabalho_______________________________________________________
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Vida Militar______________________________________________________________
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Sexualidade______________________________________________________________
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Adolescncia_____________________________________________________________
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Vida Matrimonial_________________________________________________________
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HISTRIA MDICA (Actual, antecedentes fsicos e psicolgicos):

Presena de histria de doena fsica significativa/internamento na infncia, adolescncia

e idade adulta: ___________________________________________________________
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Utilizao de medicao: __________________________________________________

Estado de sade actual: ____________________________________________________

Padres de sono: _________________________________________________________

Padres de alimentao e bebida: ____________________________________________

Padres de actividade fsica: ________________________________________________

Padro de vigilncia mdica: ________________________________________________

Observaes: ____________________________________________________________
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DADOS DE VIDA ACTUAL

Interesses________________________________________________________________
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Relaes sociais__________________________________________________________
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 EXPLORAO COMPLEMENTAR

Instrumentos administrados_________________________________________________
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Observao do paciente face situao de avaliao______________________________

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Resultados obtidos________________________________________________________
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Concluses______________________________________________________________
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Observaes_____________________________________________________________
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 RELATRIO DA SESSO DE ADMINISTRAO DO

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DIAGNSTICO / PROGNSTICO / INDICAES TERAPUTICAS

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