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Anamnese 
I. IDENTIFICAÇÃO 
Nome: _______________________________________________________________________ 
Idade:______________________________ Data de Nascimento: _______/_______/_________ 
Cor de pele: ☐ Branco/a ☐ Pardo/a ☐ Amarelo/a ☐ Preto/a ☐ Indígena ☐ Outra: ___________ 
Identidade de Gênero: ☐ Mulher Cisgênero ☐ Mulher Trans ☐ Travesti ☐ Outra. 
 ☐ Homem Cisgênero ☐ Homem trans ☐ Não binárie 
Expressão de Gênero: ☐ Cisgênero ☐ Não Binárie ☐ Travesti ☐ Outros: 
Orientação sexual: ☐ Bissexual ☐ Gay ☐ Lésbica ☐Heterossexual ☐ Outra. 
Pronome____________________. 
Escolaridade: __________________________________________________________________ 
Curso: ________________________________Faculdade: ______________________________ 
Período: ____________Telefone: ____________________ Religião: ______________________ 
Ocupação Atual: _______________________________________________________________ 
Cidade: ________________________________Estado: ________________________________ 
Endereço: ____________________________________________________________________ 
Estado Civil: __________________________________________________________________ 
Cônjuge (nome, idade e profissão): ________________________________________________ 
Filhos: ( ) Não ( ) Sim. Idade: ___________________________________________________ 
Já se submeteu à psicoterapia? 
( ) Não ( ) Sim Há quantos tempo? ________________________________________ 
 Duração do tratamento? ____________________________________ 
 
II. Doenças Fisiológicas: 
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III. Estressores psicossociais: 
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IV. Doenças importantes que teve: 
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V. Medicação que está tomando: 
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VI. Medicação alternativa (chás, compostos, etc.) 
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VII. Relacionamentos importantes: 
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VIII. QUEIXA PRINCIPAL E OUTRAS QUEIXAS 
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IX. Há quanto tempo apresenta? 
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X. Transtornos psiquiátricos anteriores: 
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Histórico da Doença Atual: 
I. Início da patologia: 
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II. Frequência: 
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III. Intensidade: 
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IV. Tratamentos anteriores: 
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V. Medicamentos: 
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VI. Sintomas apresentados: 
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VII. Eventos traumáticos de vida: 
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VIII. Eventos/fatores que precipitam ou agravam crises: 
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Uso de drogas? ________________________________________________________________ 
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Tentativa de suicídio? ___________________________________________________________ 
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IX. Transtornos psiquiátricos familiares: 
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X. RELACIONAMENTO COM PARCEIRO: 
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XI. VIDA SEXUAL ATUAL: 
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XII. SITUAÇÃO FINANCEIRA: 
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XIII. ABORTOS ESPONTÂNEOS/PROVOCADOS: 
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XIV. PRINCIPAIS LAZERES, VIDA SOCIAL: 
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XV. OBSERVAÇÕES SOBRE DINÂMICA FAMILIAR ATUAL: 
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III – DADOS FAMILIARES (caso resida com os pais) 
Nome do Pai: ________________________________________________ Idade: ____________ 
Profissão: ____________________________________________________________________ 
Nome da Mãe: _______________________________________________ Idade: ____________ 
Profissão:_____________________________________________________________________ 
Nº de irmãos / Sexo / Idades: __________________________________ 
 
 
Posição no bloco familiar: ________________________________________________________ 
Reside com: ___________________________________________________________________ 
Pais: ( ) Casados ( ) Separados 
Filho: ( ) Biológico ( ) Adotivo, Se SIM desde quando? ________________________________ 
É ciente de sua adoção? ( ) Sim ( ) Não 
Reação à situação: 
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Histórico Pessoal: 
I. Infância: 
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II. Rotina: 
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III. Vícios: 
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IV. Hobbies: 
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Exame Psíquico: 
I. Aparência: 
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II. Comportamento: 
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III. Atitude para com o entrevistador: 
( ) Cooperativo ( ) Resistente ( ) Indiferente 
 
IV. Orientação 
( ) Auto-identificatória ( ) Corporal ( ) Temporal ( ) Espacial 
( ) Orientado em relação a patologia 
 
Observações: 
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V. Vigilância: 
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VI. Tenacidade: 
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Memória 
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Inteligência 
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VII. Sensopercepção 
( ) Normal ( ) Alucinação 
 
VIII. Pensamento 
( ) Acelerado ( ) Retardado ( ) Fuga ( ) Bloqueio ( ) Prolixo 
( ) Repetição – Conteúdo ( ) Obsessões ( ) Hipocondrias ( ) Fobias ( ) Delírios 
 
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- expansão do eu: (grandeza, ciúme, reivindicação, genealógico, místico, de 
missão salvadora, deificação, erótico, de ciúmes, invenção ou reforma, idéias 
fantásticas, excessiva saúde, capacidade física, beleza...). 
- retração do eu: (prejuízo, auto-referência, perseguição, influência, 
possessão, humildades, experiências apocalípticas). 
- negação do eu: (hipocondríaco, negação e transformação corporal, auto-
acusação, culpa, ruína, niilismo, tendência ao suicídio). 
 
 
 
IX. Linguagem 
( ) Disartrias (má articulação) 
( ) Afasias, verbigeração (repetição de palavras) 
( ) Parafasia(emprego inapropriado de palavras com sentidos parecidos) 
( ) Neologismo 
( ) Mussitação (voz murmurada em tom baixo) 
( ) Logorréia (fluxo incessante e incoercível de palavras) 
( ) Para-respostas (responde a uma indagação com algo que não tem nada a ver com o que foi 
perguntado) 
 
X. Afetividade 
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XI. Humor 
( ) Normal ( ) Exaltado ( ) Baixa De Humor 
( ) Quebra súbita da tonalidade do humor durante a entrevista 
 
AMBIENTE DE TRABALHO OU ESTUDOS 
 
Vai bem no curso ou trabalho? ( ) Sim ( ) Não 
Dificuldade em relacionar-se? ( ) Sim ( ) Não 
Quais? 
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Amigos com facilidade? 
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Adapta-se facilmente ao meio? 
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Prefere ficar só ou com amigos? 
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VI - PARTICIPA DE ALGUMAS ATIVIDADES EXTRA? 
( ) Sim ( ) Não Qual(is)? 
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