JALYLI LOYOLA BARBOSA

CRP 03/18499
PSICÓLOGA CLÍNICA E
ORGANIZACIONAL
PSICOONCOLOGIA, CUIDADOS PALIATIVOS
PERDAS E LUTO

ANAMNESE PSICODIAGNÓSTICA

Data do atendimento: ____/____/____

Pacote/valor: ________________________________

Identificação:
Nome: ___________________________________________________________________
Idade: __________Sexo: _________________ Nacionalidade: ______________________
Estado Civil: ____________________ Data de nasc.:______________________________
Escolaridade: __________________________________________________________
Profissão:________________________________________________________________
Residência (cidade/estado): __________________________________________________
Telefones para contato: _____________________________________________________

Atendimento:
Frequência:___________________________ Data/hora:___________________________

Queixa Principal:
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Secundária:
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omas:
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Desde quando apresenta a queixa:

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Quais as mudanças que ocorreram/ o que afetou:

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 JALYLI LOYOLA BARBOSA
CRP 03/18499
PSICÓLOGA CLÍNICA E
ORGANIZACIONAL
PSICOONCOLOGIA, CUIDADOS PALIATIVOS
PERDAS E LUTO

Frequência/ intensidade/ duração:

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O que já tentou fazer para solucionar:

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Um exemplo de ocorrência:
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Manifestou alguma crise recentemente? Riscos e possíveis crises imediatas (grau de

urgência):
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Histórico Pessoal:

Infância:__________________________________________________________________
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Rotina:___________________________________________________________________
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Trabalho:_________________________________________________________________
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Vícios:___________________________________________________________________
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Hobbies:_________________________________________________________________
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 JALYLI LOYOLA BARBOSA
CRP 03/18499
PSICÓLOGA CLÍNICA E
ORGANIZACIONAL
PSICOONCOLOGIA, CUIDADOS PALIATIVOS
PERDAS E LUTO

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Frequência:_______________________________________________________________
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Sono:____________________________________________________________________
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Bebe? ( ) Não ( ) Sim- Qual bebida:___________________________________________

Fuma?( ) Não ( )Sim- O quê:_________________________________________________
Pratica atividade física? ( )Não ( )Sim- Qual?:___________________________________

Histórico Familiar:

Pai:_____________________________________________________________________
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Mãe:_____________________________________________________________________
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Irmaos:___________________________________________________________________
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Conjugue:________________________________________________________________
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Filhos:___________________________________________________________________
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Lar:_____________________________________________________________________
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História Patológica Pregressa (enfermidades e tratamentos atuais e anteriores):

HISTÓRICO Saúde
a) Doenças crônicas/ Quais: _________________________________________________
b) Tratamentos: ___________________________________________________________
c) Outras doenças: _________________________________________________________
d) Internações/acidentes/cirurgias:
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e) Uso de medicamentos: ____________________________________________________
f) Algum problema de saúde na família:
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Exame Psíquico:

Aparência:________________________________________________________________
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Comportamento:___________________________________________________________
 JALYLI LOYOLA BARBOSA
CRP 03/18499
PSICÓLOGA CLÍNICA E
ORGANIZACIONAL
PSICOONCOLOGIA, CUIDADOS PALIATIVOS
PERDAS E LUTO

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Humor: ( ) normal;( ) exaltado; ( )baixa de humor; ( )quebra súbita da tonalidade do

humor durante a entrevista;

HIPÓTESE DIAGNÓSTICA
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OBSERVAÇÕES E IMPRESSÕES (Espaço destinado para as perguntas elaboradas

ao longo da entrevista)
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