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Data ...../...../.....

ANAMNESE PSICOLÓGICA

Nome:________________________________________________________
Idade: ________ Sexo: ( )M ( )F
Estado Civil: ____________________________
Filhos: _________________________________
Profissão: _______________________________
Escolaridade: _______________________________
Endereço:_____________________________________________________
Bairro:________________________________Telefone:________________

Encaminhado por: ______________________________________________

Motivo da Consulta:
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Saúde Geral do Paciente (acidentes, cirurgias, tratamentos, doenças, etc):

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Apresenta algum vício? ..................... Qual? ....................................................

Já recebeu atendimento psicológico? ................................................................

Faz uso de medicação: ......................................................................................

Antecedentes familiares (depressão, ansiedade, transtornos psiquiátricos,


etc):-
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Histórico Clínico:
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Estrutura Familiar:
Convívio Social:
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Trabalho, vida conjugal, etc:


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Dados da Infância (escolaridade, convívio familiar e social, etc) :


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Observações:
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Estagiário de Psicologia: _________________________________________