ANAMNEZA

I.

II.

DATE MEDICALE
1. Compatibilitatea
/
incompatibilitatea
RH
a
prinilor
_________________________
2. Medicamente, alcool, tutun, droguri consumate n timpul sarcinii
____________________________________________________________________________
3. Suferin a ftului la natere (forceps, cezariana, travaliu prelungit):
____________________________________________________________________________
4. Greutatea la natere: _____________
5. nalimea la natere: _____________
6. Boli n primii trei ani de via: ___________________________________________
_____________________________________________________________________
7. Dezvoltare psiho-motorie: la ce vrst a mers: ____________; la ce vrst a
spus primul cuvnt: ____________; la ce vrst a mers singur la toalet:
__________; la ce vrst a mers singur la toalet: _________________
8. Tulburri de vedere: _______________________________
9. Tulburri de auz: ___________________________
10.
Deficiene motorii: __________________________
11.
Antecedente
familiale:
__________________________________________________
_____________________________________________________________________
12.
Tulburri
endocrine:
____________________________________________________
13.
Boli
cronice:
__________________________________________________________
DATE SOMATO-PSIHICE
Enurezis (nocturn sau diurn): ________________; frecvena _________________
Tulburri de somn: ___________________________________________________
Dureri de cap, ameeli (frecvena): _____________________________________
Tulburri
de
concentrare,
oboseal,
randament:
____________________________
_____________________________________________________________________
5. Fr chef, dispoziie proast: ___________________________
6. Diferite simptome (anorexie, bulimie, vom, constipaie, dureri de stomac):
____________________________________________________________________________
7. Autism infantil: ________________________
1.
2.
3.
4.

III.

DATE FAMILIALE
1. Situaia civil a prinilor: _________________________
2. Studiile prinilor: ______________________________________________________
_____________________________________________________________________
3. Profesia
i
locul
de
munc
al
prinilor:
_____________________________________
_____________________________________________________________________
4. Numr membri familie: __________
5. Venit net pe membru de familie: _____________________
6. Condiii de locuit: ______________________________________________________
_____________________________________________________________________
_____________________________________________________________________
7. Rang natere: ________________

8. Numr frai: ____________

9. Vrsta frailor: _________________________________________________________
10.
Conflicte
n
familie:
_____________________________________________________
11.
Alcoolism parental: ______________________________________________
12.
Locuiete
n
acelai
spaiu
cu:
_____________________________________________
_____________________________________________________________________
IV.

SITUAIA COLAR
1. A mers la grdini? La ce vrst? ________________________________________
2. Integrarea n grdini: _________________________________________________
_____________________________________________________________________
3. Vrsta la care a mers la coal: ____________________
4. Discipline preferate: ____________________________________________________
_____________________________________________________________________
5. Conflicte la coal: _____________________________________________________
_____________________________________________________________________
6. Activiti extracolare: __________________________________________________
_____________________________________________________________________
_____________________________________________________________________
7. Participri la diferite concursuri: __________________________________________
_____________________________________________________________________
_____________________________________________________________________
8. Rezultate deosebite la: __________________________________________________
_____________________________________________________________________
_____________________________________________________________________
9. Date despre grupul de prieteni: ______________________________________
_____________________________________________________________________
_____________________________________________________________________
10.
Alte specificri: _____________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

Data ntocmirii: ____________________

Surse:
__________________________________________________________________________________
____________________________________________________________________