ANAMNESE CASAL

IDENTIFICAO:
Nome:
Data de Nascimento: Idade:
Religio:
Endereo:
Profisso:
Telefone: E-mail:

IDENTIFICAO:
Nome:
Data de Nascimento: Idade:
Religio:
Endereo:
Profisso:
Telefone: E-mail:

MOTIVO DA CONSULTA E HISTORICO

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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QUEIXAS SECUNDRIAS:
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HISTORIA DO CASAL- como se conheceram, como se apaixonaram, pontos negativos e pontos

positivos
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HISTRIA FAMILIAR:
-Composio Familiar:________________________________________________________________
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-Dinmica Familiar:____________________________________________________________________
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-Eventos Significativos:________________________________________________________________
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HISTRIA SOCIAL:
- Vida Social:_________________________________________________________________________
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- Hbitos de lazer: _____________________________________________________________________
- Insero em Grupos:__________________________________________________________________
- Rede de Apoio:______________________________________________________________________

CONSIDERAES FINAIS:
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Gisele Ribeiro Gomes Rodrigues

Psicloga CRP08/22651