ENTREVISTA PSICOLGICA

IDENTIFICAO PESSOAL:
NOME COMPLETO: ________________________________________________________________________
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DATA DE NASCIMENTO: ____/____/_____
IDADE:______________
ESTADO CIVIL: ________________
GRAU DE INSTRUO:__________________________
PROFISSO ATUAL:____________________________
ENDEREO:________________________________________________________________________________
TELEFONES: ______________________________________________________________________________
MOTIVO DA CONSULTA/QUEIXA PRINCIPAL
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HISTRICO ESCOLAR E PROFISSIONAL (Ano de concluso da escolaridade, reprovaes e motivos das mesmas, profisses
anteriores e atuais, tempo de servio, satisfao, projetos futuros, entre outros)

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HISTRICO FAMILAR (Constituio familiar; relacionamento com a famlia atual e de origem)
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Tem algum doente na famlia? _______________________________________________________________
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Algum membro da famlia j foi internado? _______________________________________________________
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Voc herdou alguma doena da famlia? _________________________________________________________
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Algum da famlia possui vcios? _______________________________________________________________
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INDICADORES DE SADE/DOENA PESSOAL
Tem alguma doena?________________________________________________________________________
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J fez alguma cirgurgia? _____________________________________________________________________
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J foi hospitalizado? ________________________________________________________________________
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J teve tonturas, desmaios, convulses ou vertigens? _______________________________________________
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Possui algum tipo de deficincia visual/auditiva/fsica? _________________________________________________
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Costuma sentir dores de cabeas constantes e fortes? ________________________________________________
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Ouve ou j ouviu vozes sem ter algum por perto? __________________________________________________

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Dorme bem? _________________________________________________________________________________
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Usa algum medicamento? H quanto tempo? Como administrado? ______________________________________
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Fuma? H quanto tempo? Frequncia? Quantidade? ___________________________________________________
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Bebe? H quanto tempo? Qual a frequncia? ________________________________________________________
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Em que situaes costuma beber?___________________________________________________________________
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Quais as alteraes que percebe no comportamento quando bebe? _____________________________________
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Ingeriu bebida alcolica nas ltimas 24h? ____________________________________________________________
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J teve experincias com outras drogas? Tempo de uso? Frequncia? ______________________________________
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J fez algum tratamento mdico ou acompanhamento psicolgico? Quando? Por quanto tempo e por qual motivo?
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J fez avaliao psicolgica? Qual foi o resultado? Por qual motivo? ________________________________________
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Qual a ltima vez que foi ao mdico? Qual o motivo? ____________________________________________________
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ASPECTOS DA CONDUTA SOCIAL
Como voc se v? ___________________________________________________________________________
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Como voc define seu relacionamento familiar e social (amizade, namoro, trabalho, etc.)?
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Voc se recorda de alguma situao em que tenha perdido o seu controle? Como foi? ________________________
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Em quais situaes voc costuma se irritar? ______________________________________________________
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Atividades de lazer: ____________________________________________________________________________
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Religio: __________________________________
DADOS COMPLEMENTARES:

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Local,
Data

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Assinatura e carimbo do psiclogo