ANAMNESE PARA ADULTO USO DE PSI

1. Nome: ___________________________________________________________
Data de Nascimento:______/______/______ Idade:___________ Telefone:__________________________
RG:________________________ CPF:__________________________ Naturalidade:_________________________
Nome da Mãe: ______________________________________________________________________________________
Nome da Pai: ________________________________________________________________________________________
Endereço:___________________________________________________________________________________________
Formação:____________________________________ Trabalho:__________________________________________
Função no Trabalho:_______________________________________________________________________________
Inicio das sessão:_________/________/________ Medicamento:_____________________________________
 Encaminhamento (solicitar encaminhamento, caso houver):
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 Paciente sendo acompanhado por outro profissional:
Fez tratamento fonoaudiológico?__________________________________________________________
Fez tratamento psicológico?_______________________________________________________________
Fez tratamento psiquiatrico?______________________________________________________________
Outros:_______________________________________________________________________________________
1. Descrição da demanda:
História de Doença Atual/HDA (Sintomas, início do quadro, duração dos sintomas,
evolução, formas de intervenção já realizadas):
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2. Concepção:
 Foi desejada?
 Com quantos meses ou semanas descobriu que estava grávida
 Algum aborto
 Teve mais de uma gestação, me fala a orde, e como foi gestar cada uma
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3. Gestação:
 Fez pré-natal, como foi a evolução? Lembra como se sentia? Doenças /
Sensações / Quedas / Medicamentos / Exposição a Rx / Uso de cigarro, álcool e
outras drogas.
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 Nasceu de quantas semanas?_____________________________________________________
 Condições do Nascimento
( ) Em casa ( ) Maternidade

3.  Desenvolvimento do parto
( ) Natural ( ) Fórceps ( ) Cesariana
 Posição do Nascimento
( ) De cabeça ( ) Ombro ( ) Nádegas
 Desenvolvimento Neuropsicomotor
 Primeiras reações:
( ) Chorou ( ) Vermelho ( ) Roxo
( )Anóxia ( ) Icterícia ( ) Precisou de oxigênio
( ) Incubadora
 A pega da mama: ____________________________________________________________________
 Alta hospitalar:______________________________________________________________________
 Como foi o clima familiar na recepção da criança?
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4. Desenvolvimento:
 Sorriu?___________________ Equilíbrio de pescoço?__________________________________
 Engatinhou?___________________Sentou?_____________________________________________
 Andou?______________________Falou as primeiras palavras?________________________
 Quais palavras: _____________________________________________________________________
 Falou corretamente?______________Trocou letras?_________________________________
 Gaguejou?_________________Dentição ( 1 e 2)________________________________________
 Controle dos esfíncteres: Anal diurno_____________________________________________
 Vesical diurno_____________ noturno_____________________
 Estava sob os cuidados de quem?__________________________________________________
 Aconteceu algum evento que configurou maus-tratos?
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 Manipulações (quantos anos?)
 Tem alguma mania, um comportamento que se repete com frequência?
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4.  Usou chupeta __________________________Chupou o dedo ____________________________
 Roí unhas ______________________________ Puxa a orelha _____________________________
 Arranca os cabelos ___________________________ Morde os lábios ____________________
 Balança o corpo ______________________________ Mexe com as pernas _______________
 Tíques _______________________________________________________________________________
 Atitude tomada diante desses hábitos ____________________________________________
5. Sono:
 Dorme bem_____________ Pula quando dorme_______________ Horário: ____________
 Baba a noite___________________ Sudorese___________________________________________
 Acorda várias vezes durante a noite e torna a dormir____________________________
 Fala dormindo_______________Grita__________________________________________________
 Range os dentes________________ Sonâmbulo_______________________________________
 Pesadelos____________________________________________________________________________
 Atualmente, dorme no próprio quarto? Dorme com quem?
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6. Alimentação:
Foi amamentado no peito, usou mamadeira, atitude no desmame, como são os
hábitos alimentares atualmente, restrições.
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7. Familiares:
 Tem irmão? Quantos? Nome de cada e a idade
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5. _______________________________________________________________________________________________
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 Relacionamento com os irmão
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 Relaciomanto com a família.
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 È cadado? ___________________________________________________________________________
 Tem Filhos? Se sim, quantos e qual o nome de cada:______________________________
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 Como e a relação afeita de vocês em casa ? São pai que brigam discutem, como
se comportam na frente dos filhos?
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8. Escolaridade:
 È formado?__________________________________________________________________
 Gosta de estudar____________________________________________________________________
 Histórico escolar (quando começou a estudar, quais escolas, reprovação)
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6. _______________________________________________________________________________________________
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 Dificuldade em escrita______________________________________________________________
 Dificuldades em cálculo ____________________________________________________________
 Dificuldades em leitura ____________________________________________________________
 Outras dificuldades ________________________________________________________________
 Preferência lateral __________________________________________________________________
 pais tiveram dificuldades escolares?
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9. Vida social:
Prefere estar sozinho ou com os amigos, afetividade, família, amizades, parentes,
círculo de convivências.
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10. Sexualidade:
Curiosidades sexual, masturbação, educação sexual, vida sexual.
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11. Doenças:
Febre, convulsões, operações, anestesia, alergias, acidentes, quedas.
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12. Habilidades não-acadêmicas:
Esportes, bicicleta, joga bola, vídeo-game, leitura, tarefas domésticas, interesse por
mecânica, aparelhos eletrônicos, instrumentos musicais, esportes.
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13. Rotina:
 O que costuma fazer durante a semana
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14. Como e a dinamica no trabalho?
 Qual sua função no trabalho, gosta do que trabalha...?
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15. Conduta e temperamento;
 Costuma ser uma pessoa mais explosiva, hiperativa
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 Como se comporta perante o humor das pessoas ao seu redor?
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8. 16. Antecedentes psiquiátricos da família:
 Tem algum trastorno na família? Como foi conduzido o laudo e o
acompanhamento.__________________________________________________________________________
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17. Diagnosticos;
 Tem algum trastorno? Se sim, Qual?
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Já fez acompanhamento psicologico, se sim, como foi, como estava se desenvolvendo
nas sessões?
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 Quais medicamentos está tomando ou quais ele já tomou?
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18. Quais desenhos, filmes e brinquedos você gosta?
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19. Você tem algum vicio como telefone...?
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20. Observações extras:
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