DL D FIS D SRVTI

UL SI PRUL CPILULUI _______________________

1. Dt bigrfic dspr cpil:
) dt si lcul nstrii _______________________________________________
b) dmiciliul _______________________________________________________
c) l ctl cpil st ________________________________________________
2. Dt mdicl:
) ntcdnt ptlgic ______________________________________________
b) vluti psihfizic ________________________________________________
3. Structur si cmpnnt fmilii:
z)
tipul fmilii: nrml
printi dptivi
mnprntl printi dsprtiti print dcdt
b) frti/surri mi mici, mi mri ________________________________________
c) bunici si lt rud cu cr lcuist cpilul
______________________________
d) lt situtii _______________________________________________________
4. Prfsi printilr:
) tt _____________________________________________________________
b) mm ___________________________________________________________
5. Cnditii d lcuit: (s prciz n urm viziti l dmiciliul cpilului)
frt bun bun stisfctr nstisfctr
6. tmsfr si climtul ductiv din fmili:
rprturi rmnis, d ntlgr rprturi punctt d mici cnflict
dzcrduri putrnic, cnflict frcvnt fmili dzrgnizt
7. Influnt din fr fmilii (vcini, pritni):
rdus mpl frcvnt ntmpltr
8. Cmprtr cpilului n fmili:
frt bun bun stisfctr nstisfctr
9. spct l ctivittii cpilului n fmili:
- ctivitti d c ____________________________________________________
- ctivitti intlctul_______________________________________________
- ctivitti rtistic ___________________________________________________
- ctivitti prctic-gspdrsti _________________________________________

- ctivitti sprtiv