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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