ANAMNEZA

Nume si prenume: ___________________________________________________________

Data nasterii/varsta: __________________________________________________________

Sex: ____

Anamneza familial

Tatăl:

Vârsta: _____

Starea sănătăţii: ___________________________________________________________

Ocupaţia: _______________________________________________________________

Personalitatea: _________________________________________________________

Calitatea relaţiilor cu pacientul: ____________________________________________

Mama:

Vârsta: _____

Starea sănătăţii: ___________________________________________________________

Ocupaţia: _______________________________________________________________

Personalitatea: __________________________________________________________

Calitatea relaţiilor cu pacientul: _____________________________________________

Fraţii:

Nume: ___________________________

Vârstă: _________

Stare civilă: ________

Ocupaţie: _________

Personalitate: ___________________________________________________________

Afecţiuni psihice: _______________________________________________________

Calitatea relaţiilor cu pacientul: _____________________________________________

1

Poziţia socială a familiei (atmosfera în casă):

______________________________________________________________________________

______________________________________________________________________________

___________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

___________________________________________________________________________

Afecţiuni mintale în familie:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

___________________________________________________________________________

Datele personale

Sarcină şi naşteri:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

___________________________________________________________________________

Primele faze ale dezvoltării:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

2

______________________________________________________________________________

______________________________________________________________________________

___________________________________________________________________________

Starea sănătăţii în copilărie:

______________________________________________________________________________

______________________________________________________________________________

___________________________________________________________________________

„Probleme nervoase” în copilărie: (spaime, accese de furie, timiditate, balbism,

înroşirea feţei, capricii alimentare, somnambulism, enurezis, coşmaruri frecvente)

______________________________________________________________________________

______________________________________________________________________________

_____________________________________________________________________________

Şcolarizare:

______________________________________________________________________________

______________________________________________________________________________

_____________________________________________________________________________

Istoricul ocupaţional:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Istoricul menstruaţiei:

Vârsta menarhei: ____________________________

Atitudinea faţă de menstruaţie: ___________________________________________________

Vârsta menopauzei (simptome): ___________________________________________________

___________________________________________________________________________

3

___________________________________________________________________________

Istoricul cuplului:

Vârsta în momentul căsătoriei: __________________________________________________

Durata relatieie înainte de căsătorie şi durata logodnei: ________________________________

___________________________________________________________________________

Alte detalii: _________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Copiii:

Nume: ___________________________

Sex: _________

Vârstă: _________

Temperament: _________________

Dezvoltare afectivă: ___________________________________________________________

___________________________________________________________________________

Sănătate fizică şi mintală: ________________________________________________________

___________________________________________________________________________

Calitatea relatiilor cu pacientul: __________________________________________________

___________________________________________________________________________

Probleme medicale anterioare (afecţiuni, operaţii, accidente):

______________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Afecţiuni psihice anterioare (natura şi durata afecţiunilor, evoluţie):

______________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

4

Condiţii de viaţă actuale:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

___________________________________________________________________________

Relaţii: prietenii puţine

multe

superficiale

strânse

Folosirea timpului liber: pasiuni

curiozităţi

Dispoziţia predominantă:

Descriptiv:

Observational:

Caracter:

Descriptiv:

Observational:

5

Atitudini şi norme:

moral şi religios:

atitudine faţă de sănătate şi faţă de propriul corp:

Obiceiuri:

Mâncare:

Alcool:

Tutun:

Medicamente:

6