ANAMNESER O T E I R O D E E N T R E V I S T A P A R A A V A L I A Ç Ã O P S I C O L Ó G I C A

01- DADOS DE IDENTIFICAÇÃO:Nome: Data de Nascimento: Idade: Religião: Curso: Centro: Período: Matrícula: Protocolo:Contato: Encaminhado por: ENCAMINHAMENTO:PROFISSIONAL RESPONSÁVEL:

02- DADOS DE INDENTIFICAÇÃO DOS PAIS:Nome Pai: Idade:Profissão: Empresa: Grau de instrução:Nome Mãe: Idade:Profissão: Empresa: Grau de instrução:Endereço:Telefone: E-mailEstado civil:

03- QUEIXA PRINCIPAL:

04- EVOLUÇÃO DA QUEIXA:-Início da queixa:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________- Súbita ou progressiva:_____________________________________________________________________________________________________________________________________________________

- Quais as mudanças que ocorreram/ o que afetou:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

- Sintomas:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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05- QUEIXAS SECUNDÁRIAS:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

06- HISTÓRIA CLÍNICA:-Doença crônica: -_____________________________________________________________________________________-Uso de medicamentos. Quais:

_____________________________________________________________________________________-Casos de internação: _____________________________________________________________________________________-Enfrentamento: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________-Sintomas físicos e/ou psicológicos:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________- Psicoterapia/fono/fisio/neuro/psiquiatria: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________- Hábitos Alimentares:

Para crianças ou adolescentes:- Condições de Nascimento:

- Desenvolvimento Neuropsicomotor: - Doenças infantis: - Casos de convulsões,epilepsia,desmaios etc: -

07- HISTÓRIA FAMILIAR:Composição Familiar: (genotograma)

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-Dinâmica Familiar:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________- Eventos Significativos:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________-Rede de Apoio:

08- HISTÓRIA SOCIAL:- Vida Social: - Hábitos de lazer: - Inserção em Grupos: - Rede de Apoio:

09- DADOS ESCOLARES:- Casos de reprovação:

- Áreas de dificuldade: _____________________________________________________________________________________- Hábitos de Estudo:.

10- CONSIDERAÇÕES FINAIS::________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

11- SUGESTÃO DE ENCAMINHAMENTO:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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_____________________________________Assinatura do profissional

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