ANAMNESE SIMPLIFICADA CASAL
Nome : _____________________________________________ Nome : _____________________________________________
Estado Civil: _________________________________________ Estado Civil: _________________________________________
Data nascimento: _____________________________________ Data nascimento: _____________________________________
Natural de: __________________________________________ Natural de: __________________________________________
Grau de instrução: ____________________________________ Grau de instrução: ____________________________________
Profissão: ___________________________________________ Profissão: ___________________________________________
Telefone: ___________________________________________ Telefone: ___________________________________________
Inclinação religiosa: ___________________________________ Inclinação religiosa: ___________________________________
Filhos: ______________________________________________ Filhos: ______________________________________________
Netos: ______________________________________________ Netos: ______________________________________________
Hobbies: ____________________________________________ Hobbies: ____________________________________________
Álcool: _________ Fumo: __________ Drogas: ____________ Álcool: _________ Fumo: __________ Drogas: ____________
Já fez terapia: ______ Motivo: __________________________ Já fez terapia: ______ Motivo: __________________________
Obs: Obs:
Encaminhados por: __________________________ Motivo do encaminhamento: ________________________________________
Uso de medicação: ________ Qual? _______________________________________ Por quem?______________________________
Vida Familiar
Histórico do relacionamento: ___________________________________________________________________________________
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Histórico do casamento: _______________________________________________________________________________________
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Dinâmica familiar (lar): _________________________________________________________________________________________
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Relacionamentos familiares (família direta): ________________________________________________________________________
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Relacionamentos familiares (parentes): ___________________________________________________________________________
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Vida sexual (adolescência/ atual) ________________________________________________________________________________
(HP) Histórico Patológico (pessoal e familiar): ______________________________________________________________________
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Rio de Janeiro, ____de _____________________de ______________
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PSICÓLOGA
