EVALUAREA COMPLEX A ADULTULUI

I. Date personale
Nume, prenume___________________________________________________
Data, luna, anul i locul naterii _________________________________________
Starea civil ________________________________________________________
Studii _______________ ocupaia_______________________________________
Domiciliul ___________________________________________________________

II. Starea de sntate

Istoric medical
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________
Starea de sntate prezent
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________
Starea emoional
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________

IV.Istoric social
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

IV. Aspecte privind mediul de via

Locuin, utiliti :
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Situaia financiar:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

______________________________________________________________________________
Angajarea n cmpul muncii:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Gradul de independen
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Relaiile sociale
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Timpul liber i odihna
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Comunicarea i accesul la informaii
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

V. Concluzii i recomandri
___________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Data
Asistentul social
Beneficiarul