Rebeca dos santos Ivantes Gomes

Psicóloga CRP:05-57106
Tel:(21) 98283-3946
rebecaivantesgomes@yahoo.com
ANAMNESE
01- DADOS DE IDENTIFICAÇÃO:
Nome:
Data de Nascimento: Idade:
Religião:
Encaminhado por:
ENCAMINHAMENTO:
PROFISSIONAL RESPONSÁVEL:
02- DADOS DE INDENTIFICAÇÃO DOS PAIS(quando Infantil)
Nome Pai: Idade:
Profissão: Empresa:
Grau de instrução:
Nome Mãe: Idade:
Profissão: Empresa:
Grau de instrução:
Endereço:
Telefone: E-mail:
Estado civil:
03- QUEIXA PRINCIPAL:
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04- EVOLUÇÃO DA QUEIXA:

-Início da queixa:______________________________________________________________________
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- Súbita ou progressiva:_________________________________________________________________
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- Quais as mudanças que ocorreram/ o que afetou:____________________________________________

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- Sintomas:___________________________________________________________________________
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05- QUEIXAS SECUNDÁRIAS:

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06- HISTÓRIA CLÍNICA:

-Doença crônica:_______________________________________________________________________
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-Uso de medicamentos? Se sim, quais:______________________________________________________

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-Casos de internação:___________________________________________________________________
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-Enfrentamento: _______________________________________________________________________
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-Sintomas físicos e/ou psicológicos:________________________________________________________
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- Psicoterapia/fono/fisio/neuro/psiquiatria:
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- Hábitos Alimentares:__________________________________________________________________
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Para crianças ou adolescentes:

- Condições de Nascimento:______________________________________________________________
- Desenvolvimento Neuropsicomotor:______________________________________________________
- Doenças infantis:_____________________________________________________________________
- Casos de convulsões,epilepsia,desmaios etc:________________________________________________
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07- HISTÓRIA FAMILIAR:
Composição Familiar:___________________________________________________________________
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Dinâmica Familiar:____________________________________________________________________
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- Eventos Significativos:________________________________________________________________
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-Rede de Apoio:_______________________________________________________________________

08- HISTÓRIA SOCIAL:

- Vida Social: _________________________________________________________________________
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- Hábitos de lazer: _____________________________________________________________________
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- Rede de Apoio: ______________________________________________________________________

09- DADOS ESCOLARES( se necessário)

- Casos de reprovação:__________________________________________________________________
- Áreas de dificuldade:__________________________________________________________________
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- Hábitos de Estudo:____________________________________________________________________

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Assinatura do profissional

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