ANAMNEZA INTERVIU CLINIC

DATE PERSONALE SI SOCIALE:

Numele si prenumele pacientului: ________________________________ Data si locul nasterii: Ziua_____ Luna____________ Anul_____
Localitatea: _____________________________ Judetul: ______________________________________________ CNP:

Domiciliul:
Localitatea:__________________Strada:_______________ Nr.:___ Bl.___ Sc.___ Apt.___Telef.:Fix:______________Mobil: ______________
Locul de munca:
Relatii la locul de munca:
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Tipul familiei de provenienta:
Tip familie:______________________alcatuita din__________________________________________________________________________
Parinti:
Tata: ___________________________________________________________________________________________________________

Mama: __________________________________________________________________________________________________________
Relatiile din trecut cu parintii: ________________________________________________________________________________________
Relatiile actuale cu parintii: __________________________________________________________________________________________
Frati: _______________________________________________________________________________________________________________
Relatiile din trecut cu fratii: __________________________________________________________________________________________
Relatiile actuale cu fratii: ____________________________________________________________________________________________
Surori: ______________________________________________________________________________________________________________
Relatiile din trecut cu surorile: _______________________________________________________________________________________
Relatiile actuale cu surorile: _________________________________________________________________________________________

Stare maritala: __________________ Numele sotului (sotiei)___________________ Varsta _______ Profesia ___________________________
Relatia cu sotul (sotia):
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Copii:_______________________________________________________________________________________________________________
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Relatia cu copiii: ______________________________________________________________________________________________________
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VENIT PROPRIU: ___________________________________________________________________________________________________
VENIT FAMILIAL: __________________________________________________________________________________________________

ANTECEDENTE PERSONALE:
Nr. internari in spital ____ Motivele internarii (diagnostic) ____________________________________________________________________
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Nr. internari in spitale de psihiatrie ____ Diagnostic __________________________________________________________________________

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ANTECEDENTE COLATERALE (rude grad I, a se specifica doar bolile mintale, neurologice)

Parinti:
Tata: ___________________________________________________________________________________________________________
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Mama: _________________________________________________________________________________________________________
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Frati: __________________________________________________________________________________________________________
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Surori: ________________________________________________________________________________________________________
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Hobby-uri: __________________________________________________________________________________________________________
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ACUZE PREZENTE: ________________________________________________________________________________________________

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ANALIZE MEDICALE EFECTUATE:

In ultimele trei luni: ___________________________________________________________________________________________________
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In ultimele sase luni: ___________________________________________________________________________________________________
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Evaluare psihica efectuata _______ Data efectuarii ____________ Diagnostic __________________________________________________

Medicul care a pus diagnosticul ________________________________________________________________________________________
Institutia ___________________________________________________________________________________________________________

Evaluare psihologica efectuata _________ Data efectuarii _____________ Diagnostic ___________________________________________

Psiholog examinator __________________________________________________________________________________________________
Institutia ___________________________________________________________________________________________________________

RECOMANDARI:
1. Analize medicale
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2. Regim alimentar
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