INTERVIU CLINIC

1. ANAMNEZA

Numele:________________________________________________________

Data naterii:____________________________________________________

Locul naterii:___________________________________________________

Structura familial:_______________________________________________

Condiii materiale:________________________________________________

Statut personal:_________________________________________________
profesional:_______________________________________________

Cstorit/necstorit:______________________________________________

Copii:___________________________________________________________

Relaii cu prinii:________________________________________________
soul/soia:______________________________________________
copiii:_________________________________________________

Evenimente de via:_______________________________________________
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Relaii la locul de munc:___________________________________________

Educaia n familie:________________________________________________

Grad de instruire:__________________________________________________

2. MOTIVELE INTERNRII

Internarea (cu voia lui, urgen etc.):___________________________________

Debutul bolii:_____________________________________________________

Prima internare:___________________________________________________

Descrierea simptomelor:____________________________________________
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Caracterul bolii:___________________________________________________

Circumstanele debutului:____________________________________________
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3. ANTECEDENTE HEREDO-COLATERALE
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4. ANTECEDENTE PERSONALE:

Menstruaia:______________________________________________________

Menopauza:______________________________________________________

Internri cu alte probleme:___________________________________________

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Intervenii chirurgicale:______________________________________________

Traumatisme:_____________________________________________________

5. EXAMINAREA SOMATIC GENERAL

Mersul:__________________________________________________________

Motricitatea:______________________________________________________

Sensibilitatea:_____________________________________________________

Coordonare:_______________________________________________________

Reflexe:__________________________________________________________

6. EXAMEN PSIHIATRIC

inuta vestimentar:________________________________________________

Stare de igien:____________________________________________________

Facies:___________________________________________________________

Privire:___________________________________________________________

Mimic i pantomimic:_____________________________________________

7. ORIENTARE SPAIO-TEMPORAL

Allopsihic:______________________________________________________

Autopsihic:______________________________________________________

8. FUNCII PSIHICE:

Afectivitatea (dispoziii):____________________________________________
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Voina i activitatea:________________________________________________
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Atenia voluntar:________________________________________________
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involuntar:______________________________________________
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Senzaii i percepii (iluzii i halucinaii):_______________________________

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Gndirea: coeren/incoeren/ritm:__________________________________
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flux ideativ:____________________________________________

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idei obsesivo-fobice:____________________________________
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idei dominante:_________________________________________
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idei prevalente:_________________________________________
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idei delirante/expansive/depresive:__________________________
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Nivel intelectual:___________________________________________________

Limbaj:__________________________________________________________
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Memoria:_________________________________________________________
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Instincte: alimentar:______________________________________________
sexual:________________________________________________

Contiina (optuzii, stupoare, delirant, oniroid, crepuscular):______________

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9. RITM NICTEMERAL

Somn/comaruri/mod de trezire:_______________________________________
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