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roteiro-de-entrevista-anamnese-para-avaliacao-psicologica-l Document Transcript

  • 1. ANAMNESE R 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-mail Estado civil: 03- QUEIXA PRINCIPAL: 04- EVOLUÇÃO DA QUEIXA: -Início da queixa:______________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ - Súbita ou progressiva:_________________________________________________________________ ____________________________________________________________________________________ - Quais as mudanças que ocorreram/ o que afetou:____________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ - Sintomas:___________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 1
  • 2. 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) 2
  • 3. -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: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 3
  • 4. __________________________________________________________________________________ _____________________________________ Assinatura do profissional 4