Psico
análi se
Marcos Goulart - psicanalista 11 7685 3787
[email protected]
Nome: Data de Nascimento: Idade: End.: Estado Civil:
E-mail: Profissão: Tel.: Escolaridade:
Atendimento
Janeiro Dia Mê s
Fevereiro
Março
Abril
Maio
Junho
Julho
Agosto
Setembro
Outubro
Novembro
Dezembro
Anamnese Psicanalítica
Trabalha: __________________________ ______________________________________ ______________ __ Salários: 1 ( ) 5 ( ) +6 ( )
2( )
3( )
4( )
Nome do ____________________________ _________________________________________ __________________________ ___________________________ ___________________ _____
Pai:
Doenças do ____________________________ _________________________________________ __________________________ ___________________________ _________________ ___
Pai:
Reside com você: Sim ( )
Não ( )
Idade do Pai: ____________________________ ____________________________ Escolaridade: __________________________ ____________________________ __ Religião: __________________________ ________________________________ ______ Relacionamento: ____________________________ _________________________________________ __________________________ ___________________________ ___________________________ __________________ _____ ____________________________ _________________________________________ __________________________ ___________________________ ___________________________ __________________ _____ ____________________________ _________________________________________ __________________________ ___________________________ ___________________________ __________________ _____ ____________________________ _________________________________________ __________________________ ___________________________ ___________________________ _____________
Nome da ____________________________ _________________________________________ __________________________ ___________________________ __________________ ____
Mãe:
Doenças da ____________________________ _________________________________________ __________________________ ___________________________ ________________ __
Mãe:
Reside com você: Sim ( )
Não ( )
Psico
análi se
Marcos Goulart - psicanalista 11 7685 3787
[email protected] Idade da Mãe: __________________________ __________________________ Escolaridade: __________________________ ___________________________ _ Religião: __________________________ _______________________________ _____ Relacionamento: ____________________________ _________________________________________ __________________________ ___________________________ ___________________________ __________________ _____ ____________________________ _________________________________________ __________________________ ___________________________ ___________________________ __________________ _____ ____________________________ _________________________________________ __________________________ ___________________________ ___________________________ __________________ _____ ____________________________ _________________________________________ __________________________ ___________________________ ___________________________ _____________
Cônjuge: __________________________ _______________________________________ __________________________ ___________________________ _________________________ ___________ Escolaridade: __________________________ ____________________________ __ Religião: __________________________ ________________________________ ______ Idade: __________________________ __________________________________ ________ Irmãos/Idades: ____________________________ _________________________________________ __________________________ ___________________________ __________________ ____ Filhos/Idades: ________________________ _______________________________________ ____________________________ _________________________ ____________________ ________
Porque está fazendo terapia/análise: ____________________________ _________________________________________ __________________________ ___________________________ ___________________________ __________________ _____ ____________________________ _________________________________________ __________________________ ___________________________ ___________________________ __________________ _____ ____________________________ _________________________________________ __________________________ ___________________________ ___________________________ ______________ _
O que mais quer hoje ____________________________ _________________________________________ __________________________ ___________________________ ___________________________ __________________ _____ ____________________________ _________________________________________ __________________________ ___________________________ ___________________________ __________________ _____ ____________________________ _________________________________________ __________________________ ___________________________ ___________________________ ______________ _
Acidentes ou doenças na ____________________________ _________________________________________ ________________________ ___________
fase
Quantos amigos ____________________________ _________________________________________ __________________________ _________________________ ____________
de
criança possui
Psico
análi se
Marcos Goulart - psicanalista 11 7685 3787
[email protected]
Passatempo ____________________________ _________________________________________ __________________________ _________________________ ____________
preferido
Medos _________________________ _____________________________________ ___________________________ ____________________________ _________________________ ______________ __ Fantasias ____________________________ _________________________________________ __________________________ ___________________________ _______________________ _________ Fantasmas ____________________________ _________________________________________ __________________________ ___________________________ ______________________ ________ Quem é o seu ____________________________ _________________________________________ __________________________ ___________________________ ______________
amor
Que tipo de pessoa prefere ________________________ pobre _____________ rica ________________ Como começou sua ____________________________ _________________________________________ __________________________ __________________ _____
vida
sexual
Sente prazer ____________________________ _________________________________________ __________________________ ________________________ ___________
(orgasmo)
Gosta Gosta das pessoas: pessoas: superiore superiores s _________ _____________ ______ __ inferiores inferiores _________ ______________ _______ __ iguais _______________ Gravidez ____________________________ _________________________________________ __________________________ ___________________________ ___________________________ __________________ _____ ____________________________ _________________________________________ __________________________ ___________________________ ___________________________ _______________ __ Parto ____________________________ _________________________________________ __________________________ ___________________________ ___________________________ __________________ _____ ____________________________ _________________________________________ __________________________ ___________________________ ___________________________ _______________ __ Fase Oral ____________________________ _________________________________________ __________________________ ___________________________ ___________________________ __________________ _____ ____________________________ _________________________________________ __________________________ ___________________________ ___________________________ ________________ ___
