ANAMNESE

DADOS SOBRE O CLIENTE

1- IDENTIFICAÇÃO

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IDADE__________________________DATA NASC._____/______/_____ SEXO________________________
NATURALIDADE___________________EST.CIVIL__________________ESCOLARIDADE_____________________
PROFISSÃO___________________________RELIGIÃO___________________PRATICANTE? SIM ( ) NÃO ( )

DADOS SOBRE A FAMÍLIA

CÔNJUGE___________________________________________________________________IDADE__________
PROFISSÃO______________NATURALIDADE____________ESCOLARIDADE________________________
FILHOS (SEXO)______________________________________________IDADE_________________________
NOME DO PAI__________________________________________________IDADE________________________
PROFISSÃO___________________NATURALIDADE_____________ESCOLARIDADE___________________
NOME DA MÃE___________________________________________________IDADE___________________
PROFISSÃO___________________NATURALIDADE_________________ESCOLARIDADE________________
IRMÃOS________________________________________________________________________________________
POSIÇÃODENASCIMENTO:_________________________________________________________________
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ENDEREÇO RESIDENCIAL____________________________________________________________________
ENDEREÇO COMERCIAL:___________________________________________________________________
TEL. CELULAR _______________________________TEL. RESIDENCIAL____________________________

CONDIÇOES SÓCIO-ECONÔMICAS – RENDA FAMILIAR

Até 1 salário mínimo ( ) De 1 a 2 salários mínimos ( )
De 2 a 3 salários mínimos ( ) De 3 a 5 salários mínimos ( )
De 5 a 10 salários mínimos ( ) De 10 a 20 salários mínimos ( )
Mais de 20 salários mínimos ( )

QUANTAS PESSOAS TRABALHAM NA FAMÍLIA__________________________QUAIS?__________________

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A FAMÍLIA RESIDE EM:
CASA APARTAMENTO
( ) Própria ( ) Quitado
( ) Alugada ( ) Financiado
( ) Cedido ( ) Outro
OUTRASOBSERVAÇÕES:_____________________________________________________________________________
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CONSULTA PSICOLÓGICA ANTERIORMENTE? SIM ( ) NÃO ( )

CONSULTA PSIQUIÁTRICA ANTERIORMENTE? SIM ( ) NÃO ( )
ENCAMINHADO POR:______________________________________________________________________
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2. MOTIVO DA PROCURA DOS SERVIÇOS

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3. HISTÓRICO DAS DIFICULDADES RELATADAS (desde quando apresenta a queixa)

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4. DINÂMICA FAMILIAR (considerar as famílias nuclear e constituída)

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5. DINÂMICA DO RELACIONAMENTO SOCIAL

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6. DINÂMICA PROFISSIONAL E ESCOLAR

A) ESCOLAR_____________________________________________________________________________
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B)PROFISSIONAL___________________________________________________________________________________
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7. SAÚDE
a) PESSOAL
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b) FAMILIAR
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8. ASPECTOS SIGNIFICATIVOS PERCEBIDOS DURANTE A ENTREVISTA

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9. PARECER DIAGNÓSTICO –Sintomatologia relatada, relacionada com a Psicodinâmica do cliente
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10. ORIENTAÇÃO TERAPÊUTICA (ENCAMINHAMENTOS)

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Teresina, PI____/____/_____