I – DADOS BIOGRÁFICOS

(1ª Fase)

Nome: _________________________________________________________________________
Idade:__________________ Sexo:__________________ Estado civil:______________________
Habilitações literárias:_____________________________________________________________
Profissão:________________________________________________________________________
Agregado Familiar:________________________________________________________________
Residência:______________________________________________________________________
Contacto telefónico:________________________________________________________________

II – MOTIVO DA CONSULTA
(QUEM ENVIA, documentos em anexo e queixas. BREVE DESCRIÇÃO da forma como o doente
se apresentou na primeira consulta: como vem, sozinho ou acompanhado e com quem; apreciação
física e psicológica: como veste, postura, contacto visual, tom de voz; tipo de discurso:
monocórdico, ritmo, entoação, postura e gestos; conteúdo verbal: directo, evasivo, difícil organizar
as respostas, circunstancial (fala de tudo menos do que importa), prolixo; avaliação do estado
emocional: ansiedade, timidez – o que nos parece a nós)
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 III – DIFICULDADES ACTUAIS
(2ª Fase: A-B-C)

PORQUE VEIO: porque veio à consulta; como descreve os seus problemas.

(Ex.: “das queixas actuais concluímos serem 3 as áreas de problemas” – enunciar as 3 áreas, fazer
uma hierarquia (apresentá-las por ordem) e determinar grau de perturbação subjectiva que causam –
pedir para avaliar numa escala de 0-100)
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1. Por cada ÁREA PROBLEMA

QUE acontece a nível (B – forma do comportamento):

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  Emocional_________________________________________________________________
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 Motor_____________________________________________________________________
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QUANDO acontece (A – situacional)
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ONDE acontece (em casa, local de trabalho, casa de amigos, vizinhos, etc) (A – situacional)
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COM QUEM acontece (quem está presente; se está sozinho ou acompanhado e por quem)
(A – interpessoal)
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Há estímulos desencadeadores? (o que está a pensar, fazer e sentir?)
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Com que FREQUÊNCIA acontece (vezes/hora; dias/semana, etc – quantificar)
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QUANTO tempo dura e INTENSIDADE
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Pedir o maior número de exemplos possíveis, sobretudo saber quando foi a última vez que
aconteceu e como foi
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O que acontece a seguir a cada episódio (como sente o corpo, o que pensa, o que faz, que emoções
tem) (C – pessoal)
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O que pensa que faz aumentar o problema?
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O que pensa que faz diminuir o problema?
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Há outras coisas que faça ou que aconteçam que ajudem a resolver o problema? E noutras áreas,
como lida com os problemas? (coping em geral)
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2. Como o problema interfere nas várias áreas de vida

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  Passatempos________________________________________________________________
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 Actividade em geral__________________________________________________________
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3. Impacto nos outros (C – interpessoais)

(como é que o problema afecta os outros que o rodeiam – o que eles dizem, pensam e como se
sentem em relação ao problema. Ex.: “o meu marido agora até lava sempre a loiça”)
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4. Grau de invalidação
(o que deixou de fazer; em que medida a vida mudou desde que o problema aconteceu; o que
começou a fazer que não fazia antes; o que passaria a fazer se o problema desaparecesse; onde não
vai, quem deixou de ver, etc)
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5. Áreas de bom funcionamento e interesses

(o que gosta de fazer: em casa, hobbies, férias)
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6. Avaliação da motivação (importante!)

 A que atribui a sua doença (como percepciona a doença e a sua manutenção – como
começou e como continua)
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 Grau de invalidação (quanto maior o grau de invalidação, maior a motivação para o
tratamento)
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  Objectivos e expectativas sobre a terapia (o que espera vindo aqui)
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7. Resultados das escalas

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IV – INICIO E DESENVOLVIMENTO DAS DIFICULDADES

(3ª Fase)

Quando foi a primeira ocorrência do problema?

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Quais os A-B-C? O que pensou? O que sentiu no corpo? Nas emoções? O que fez?
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O que foi? Como foi? Com quem foi? (as mesmas questões que se fazem nas dificuldades actuais)
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O que é que nessa altura estava a acontecer na sua vida? (acontecimentos de vida)
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Desenvolvimento: O que a partir daí mudou/variou/evoluiu? O que fez para ultrapassar o problema?
Resultados dessas tentativas: o que acha que nesses tratamentos correu bem e o que correu mal
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V – HISTÓRIA DO DESENVOLVIMENTO E APRENDIZAGEM PRÉVIA

(4ª Fase)

a) Gravidez e parto (desejado, planeado, a tempo):

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b) Desenvolvimento psicomotor (linguístico, esfincteriano, social, etc)
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c) História de reforços, sensibilidade diferencial (descrição das pessoas significativas na
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d) Padrões de interacção familiar
 Relação com os pais (descrever pai e mãe)
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 Relação com os irmãos
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 Relações dos pais entre si
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 Relações entre os irmãos
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 Relação entre os pais e os outros irmãos
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 Existência de alianças e coligações
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 Padrões de comunicação (ex: quando queria sair como é que fazia? O que lhe
respondiam?)
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  Método de resolução de problemas (ex: quando se chateava com alguém como é que
resolvia a situação?)
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 Reforços e punições: quem ralhava mais, quem beijava e acarinhava mais…
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e) Escolaridade
Quando começou e como evoluiu; gostava? Do que gostava mais? E menos? Como foi a integração
no sistema e nos diversos subsistemas escolares
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f) Vida Profissional
Como é? Está satisfeito? Tem projectos para o futuro? Quais as relações que tem com os colegas e
chefes… Se tem problemas no trabalho como os resolve?
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g) Relações Interpessoais
 Amigos de infância
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 Amigos na Adolescência
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 Amigos “actuais” – no trabalho
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 Família “actual”
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 Costuma sair com quem? E antes do problema?
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 Relações interpessoais dos pais (se saíam, tinham amigos, recebiam visitas…)
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 Estatutos e papéis: exigências e expectativas dos outros
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 Existiam conflitos com/nos grupos de relação
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 Alcunhas
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h) Religião
Na infância, adolescência e actualmente. Crenças transmitidas e em que medida acredita nelas (em
que medida elas são mantidas)
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i) Outras relações afectivas significativas

Namoros, casamentos, relações conjugais
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j) Sexualidade
Que informação sexual dispõe (suficiente, insuficiente). Quem a transmitiu, onde a obteve;
Menarca, 1ª erecção (o que lhe disseram, o que pensou? 1ª vivência da sexualidade; quando se
apercebeu que tinha um corpo sexuado (excitação não necessariamente um acto sexual)
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Masturbação, crenças transmitidas (conselhos dados); situação actual da sexualidade; grau de
satisfação obtido
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k) Outros acontecimentos significativos importantes não mencionados antes:
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l) História de saúde
História médica e psiquiátrica da família, se toma medicação actual e estado de saúde actual
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m) Padrões de sono e alimentação

Consumo de álcool, tabaco, etc (antes e depois do problema começar houve alguma alteração?)
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n) Padrões de actividade física
Hábitos de desporto, andar a pé, está muito tempo sentado, usa transportes
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o) História de coping: (como ao longo da história pessoal foi resolvendo os problemas directa ou
indirectamente)
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p) Auto-conceito
 O que acha de si
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 O que acha que os outros acham de si
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 O que pensa que os outros pensam de si
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 Como gostaria de ser
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q) Motivação e Expectativas Terapêuticas; o que pensa ser necessário acontecer para deixar de ter
problemas
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r) Valores (qualquer coisa que preza porque acha bem)

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s) Crenças (algo em que se acredita independentemente de se achar bom ou mau)

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t) Objectivos de vida:
 A Curto prazo
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 A Médio prazo
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 A Longo prazo
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Expectativas o que se espera que seja mais provável e menos provável que aconteça relativamente
ao projecto de vida?
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 VI – FORMULAÇÃO
(5º Fase)

Diagnóstico: de acordo com os critérios previstos na DSM-IV, podemos considerar um distúrbio de

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Factores Predisponentes
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Factores precipitantes
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Factores de Manutenção
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 VII – PROPOSTAS E ESTRATÉGIAS TERAPÊUTICAS
(6ª Fase)
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