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ANAMNESEROTEIRO DE ENTREVISTA PARA AVALIAO PSICOLGICA
01- DADOS DE IDENTIFICAO: Nome: Data de Nascimento: Religio: Curso: Centro: Perodo: Matrcula: Contato: Encaminhado por: ENCAMINHAMENTO: PROFISSIONAL RESPONSVEL:
Idade: Protocolo:
02- DADOS DE INDENTIFICAO DOS PAIS: Nome Pai: Profisso: Grau de instruo: Nome Me: Profisso: Grau de instruo: Endereo: Telefone: Estado civil: 03- QUEIXA PRINCIPAL:
Idade: Empresa: Idade: Empresa: E-mail
04- EVOLUO DA QUEIXA:-Incio da queixa:______________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ - Sbita ou progressiva:_________________________________________________________________ ____________________________________________________________________________________ - Quais as mudanas que ocorreram/ o que afetou:____________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ - Sintomas:___________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 1
05- QUEIXAS SECUNDRIAS:____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________
06- HISTRIA CLNICA:-Doena crnica: _____________________________________________________________________________________ -Uso de medicamentos. Quais: _____________________________________________________________________________________ -Casos de internao: _____________________________________________________________________________________ -Enfrentamento: _______________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ -Sintomas fsicos e/ou psicolgicos:________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ - Psicoterapia/fono/fisio/neuro/psiquiatria: _________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ - Hbitos Alimentares: Para crianas ou adolescentes: - Condies de Nascimento: - Desenvolvimento Neuropsicomotor: - Doenas infantis: - Casos de convulses,epilepsia,desmaios etc: -
07- HISTRIA FAMILIAR:Composio Familiar: (genotograma)
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-Dinmica Familiar:____________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ - Eventos Significativos:________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ -Rede de Apoio:
08- HISTRIA SOCIAL:- Vida Social: - Hbitos de lazer: - Insero em Grupos: - Rede de Apoio:
09- DADOS ESCOLARES:- Casos de reprovao: - reas de dificuldade: _____________________________________________________________________________________ - Hbitos de Estudo:.
10- CONSIDERAES FINAIS::_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
11- SUGESTO DE ENCAMINHAMENTO:_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 3
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_____________________________________Assinatura do profissional
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