Anamnese

I – Identificação

Nome:__________________________________________________________

Endereço:______________________________________________________

Telefones: ( ) _______________ ( ) ________________ ( )

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DN: ____/____/____ Idade:___________ Sexo: ( ) M ( ) F

Data inicial do tratamento:____/____/____ Estado Civil:________________

II- Histórico Familiar:

Genograma

Observações

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Como é o relacionamento familiar? (fatos traumáticos): separação dos pais,

punições severas.

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Tem irmãos, (Posição na ordem de nascimento):

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Alguém tem ou teve problemas com álcool ou drogas?

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Como é o relacionamento com os pais?
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III- História Pessoal

Problemas ao nascer/ doenças graves na infância: ( )Sim ( )Não. Quais?

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Escolaridade:__________________________ Ano de
conclusão:____/____/____

Como a avalia seu desempenho escolar ?

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Teve problemas escolares como brigas, expulsões, reprovações e evasões?

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IV- História Social (Religião, Amigos, Lazer, Esportes)

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V- História Profissional

Trabalha Atualmente? ( )S ( ) N

Profissão:_______________________________________________________
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Que ocupação já exerceu?
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VI- História Matrimonial/Sexual

Mora com quem?_________________

Teve separações?
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Qualidade no relacionamento (Atitude do parceiro em relação ao problema)

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Tem filhos ( ) S ( )N Quantos? ( Sexo, idade/estado civil)

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Algum dos filhos tem problemas de saúde?

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Está em tratamento? Qual?

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VII- História Médica/Psiquiátrica

Que doenças já teve?

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Uso de Medicamentos

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Inquérito

Queixa principal dos sintomas físicos, psicológicos e sociais decorrentes do

problema apresentado.

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XIII – Investigações:

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XIV – Plano de Atendimento

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Observações:

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Data de término do preenchimento:___/___/___

Hipótese
Diagnóstica:_____________________________________________________

Fatores de risco e mantenedores da (s) dependência (s):

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Fatores de proteção e prognóstico para progressão da dependência:

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Assinatura e carimbo