PSICOLOGIA COMPORTAMENTAL, Manuais, Projetos, Pesquisas de Psicologia Social

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Data do atendimento: ____________________________________________________________ 1 – IDENTIFICAÇÃO: Nome: _________________________________________________________________________ Idade: _____________ Sexo: __________________ Nacionalidade: ________________________ Estado Civil: ______________________ Data de nascimento: _____________________________ Grau de instrução: ________________________________________________________________ Profissão: _______________________________________________________________________ Residência (Cidade/Estado): ________________________________________________________ Telefones para contado: ___________________________________________________________ 2 – ATENDIMENTO: Frequência: ______________________________ Data/hora: ______________________________ a) Queixa Principal: _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ b) Secundária: _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ c) Sintomas: _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 3 – HISTÓRICO DA DOENÇA ATUAL: a) Início da patologia: _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ b) Frequência: __________________________________________________________________ _______________________________________________________________________________ ANAMNESE ADULTO c) Intensidade: __________________________________________________________________ _______________________________________________________________________________ d) Tratamentos anteriores: ________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ e) Medicamentos: _______________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 4 – HISTÓRICO PESSOAL: a) Infância: ______________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ b) Rotina: ______________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ c) Vícios: _______________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ d) Hobbies: _____________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 2