SPA - Serviço de Psicologia Aplicada – Curso de Psicologia – Campus Resende UNESA
ENTREVISTA DE TRIAGEM
Estagiário entrevistador:_____________________________________________________________
Professor supervisor:_______________________________________________________________
Data (s) da(s) entrevista(s): __________________________________________________________
Data em que procurou o SPA: ________________________________________________________
1 – IDENTIFICAÇÃO:
Nome:___________________________________________________________________________
Nome da mãe: ______________________________Nome do pai:___________________________
Idade:_______Data de nascimento: ___________Sexo:_____Estado civil: _____________________
Ocupação: ____________________________________Grau de instrução:____________________
Local de residência: ________________________________________________________________
Telefone: _____________________________ e.mail _____________________________________
Religião: _________________ Naturalidade: ______________ Nacionalidade: _______________
2 – INDICAÇÃO (como chegou ao SPA):_______________________________________________
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3 – QUEIXA PRINCIPAL (o que levou o paciente ou acompanhante a marcar a consulta):
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4 – HISTÓRIA DO PROBLEMA ATUAL (surgimento e evolução do problema, conseqüências na
vida do paciente, tentativas de tratamento, etc.)
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5 – HISTÓRIA FAMILIAR (estrutura familiar, problemas doenças e conflitos, história conjugal, etc.)
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6 – HISTÓRIA SOCIAL (educacional, ocupacional, econômica, habitacional, cultural, religiosa, etc.)
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7 – HISTÓRIA PESSOAL
Nascimento (gravidez e parto):________________________________________________________
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Desenvolvimento Infantil (crescimento, alimentação, aprendizado, socialização, etc.):
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Adolescência (socialização, sexualidade, comportamentos ilícitos, etc.):_______________________
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Vida Adulta (vida social, vida sexual, episódios significativos, fatos traumáticos, etc.):
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8 – HISTÓRIA PATOLÓGICA (doenças de infância, acidentes, traumatismos, internações, cirurgias,
doenças graves, psicossomáticas, uso de drogas e/ou medicamentos, etc.)
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9 – EXAME PSÍQUICO (alterações psicopatológicas marcantes):
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10 – OBSERVAÇÕES COMPLEMENTARES:
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HIPÓTESE DIAGNÓSTICA:
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INDICAÇÃO DE TRATAMENTO:
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