ANAMNESEENTREVISTA 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:

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04- EVOLUO DA QUEIXA:-Incio da queixa:______________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ - Sbita ou progressiva:_________________________________________________________________ ____________________________________________________________________________________ - Quais as mudanas que ocorreram/ o que afetou:____________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ - Sintomas:___________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

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05- QUEIXAS SECUNDRIAS:____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

06- HISTRIA CLNICA:-Doena crnica:_______________________________________________________________________ _____________________________________________________________________________________ -Uso de medicamentos? Se sim, 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:___________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Dinmica Familiar:____________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ - Eventos Significativos:________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 2

____________________________________________________________________________________ -Rede de Apoio:_______________________________________________________________________

08- HISTRIA SOCIAL:- Vida Social: _________________________________________________________________________ _____________________________________________________________________________________ - Hbitos de lazer: _____________________________________________________________________ _____________________________________________________________________________________ - Rede de Apoio: ______________________________________________________________________

09- DADOS ESCOLARES:- Casos de reprovao:__________________________________________________________________ - reas de dificuldade:__________________________________________________________________ _____________________________________________________________________________________ - Hbitos de Estudo:____________________________________________________________________

10- CONSIDERAES FINAIS::_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

11- SUGESTO DE ENCAMINHAMENTO:_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

_____________________________________Assinatura do profissional

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