This document contains a case history form for a couple seeking counseling. It collects identifying information for both partners such as name, date of birth, address, and contact details. It asks about the chief complaint and history of the issue, how the problem developed, associated symptoms, and any secondary issues. The form also inquires about the couple's history together including how they met and fell in love, positives and negatives in the relationship, family composition and dynamics, significant life events, social life and habits, community involvement, and support systems. Final notes are included for the counselor's records.

1. 1
ANAMNESE CASAL
IDENTIFICAÇÃO:
Nome: CPF
Data de Nascimento: Idade:
Religião: RG
Endereço:
Profissão:
Telefone: E-mail:
IDENTIFICAÇÃO:
Nome: CPF
Data de Nascimento: Idade:
Religião: RG
Endereço:
Profissão:
Telefone: E-mail:
MOTIVO DA CONSULTA E HISTORICO
QUEIXA PRINCIPAL:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
04- EVOLUÇÃO DA QUEIXA:
-Início da queixa:______________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
- Súbita ou progressiva:_________________________________________________________________
____________________________________________________________________________________
- Quais as mudanças que ocorreram/ o que afetou:____________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
- Sintomas:___________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

2. 2
QUEIXAS SECUNDÁRIAS:______ __________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
HISTORIA DO CASAL- como se conheceram, como se apaixonaram, pontos negativos e pontos
positivos
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
-Composição Familiar:________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
-Dinâmica Familiar:____________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
-Eventos Significativos:________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
HISTÓRIA SOCIAL DO CASAL:
- Vida Social:_________________________________________________________________________
- Hábitos de lazer: _____________________________________________________________________
- Inserção em Grupos:__________________________________________________________________
- Rede de Apoio:______________________________________________________________________
CONSIDERAÇÕES FINAIS:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Local de atendimento__________________________________________________
RJ, ____/____/____________
__________________________________
Assinatura e carimbo do psicólogo ou psicanalista