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:______________________________________________________________________
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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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2. 05- QUEIXAS SECUNDÁRIAS:
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06- HISTÓRIA CLÍNICA:
-Doença crônica: -
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-Uso de medicamentos. 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:
Para crianças ou adolescentes:
- Condições de Nascimento:
- Desenvolvimento Neuropsicomotor:
- Doenças infantis:
- Casos de convulsões,epilepsia,desmaios etc: -
07- HISTÓRIA FAMILIAR:
Composição Familiar: (genotograma)
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3. -Dinâmica Familiar:____________________________________________________________________
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- Eventos Significativos:________________________________________________________________
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-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:
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- Hábitos de Estudo:.
10- CONSIDERAÇÕES FINAIS::
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11- SUGESTÃO DE ENCAMINHAMENTO:
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4. __________________________________________________________________________________
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Assinatura do profissional
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