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INTERVIU CLINIC

1. ANAMNEZA
 Numele:________________________________________________________
 Data naşterii:____________________________________________________
 Locul naşterii:___________________________________________________
 Structura familială:_______________________________________________
 Condiţii materiale:________________________________________________
 Statut →personal:_________________________________________________
→profesional:_______________________________________________
 Căsătorit/necăsătorit:______________________________________________
 Copii:___________________________________________________________
 Relaţii cu →părinţii:________________________________________________
→soţul/soţia:______________________________________________
→copiii:_________________________________________________
 Evenimente de viaţă:_______________________________________________
________________________________________________________________
 Relaţii la locul de muncă:___________________________________________
 Educaţia în familie:________________________________________________
 Grad de instruire:__________________________________________________

2. MOTIVELE INTERNĂRII
 Internarea (cu voia lui, urgenţă etc.):___________________________________
 Debutul bolii:_____________________________________________________
 Prima internare:___________________________________________________
 Descrierea simptomelor:____________________________________________
________________________________________________________________
 Caracterul bolii:___________________________________________________
 Circumstanţele debutului:____________________________________________
_________________________________________________________________

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3. ANTECEDENTE HEREDO-COLATERALE
_______________________________________________________________________
_______________________________________________________________________
__

4. ANTECEDENTE PERSONALE:
 Menstruaţia:______________________________________________________
 Menopauza:______________________________________________________
 Internări cu alte probleme:___________________________________________
_________________________________________________________________
 Intervenţii chirurgicale:______________________________________________
 Traumatisme:_____________________________________________________

5. EXAMINAREA SOMATICĂ GENERALĂ


 Mersul:__________________________________________________________
 Motricitatea:______________________________________________________
 Sensibilitatea:_____________________________________________________
 Coordonare:_______________________________________________________
 Reflexe:__________________________________________________________

6. EXAMEN PSIHIATRIC
 Ţinuta vestimentară:________________________________________________
 Stare de igienă:____________________________________________________
 Facies:___________________________________________________________
 Privire:___________________________________________________________
 Mimică şi pantomimică:_____________________________________________

7. ORIENTARE SPAŢIO-TEMPORALĂ
 Allopsihică:______________________________________________________
 Autopsihică:______________________________________________________

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8. FUNCŢII PSIHICE:
 Afectivitatea (dispoziţii):____________________________________________
_________________________________________________________________
_________________________________________________________________
 Voinţa şi activitatea:________________________________________________
_________________________________________________________________
_________________________________________________________________
 Atenţia →voluntară:________________________________________________
_________________________________________________________________
→involuntară:______________________________________________
_________________________________________________________________
_
 Senzaţii şi percepţii (iluzii şi halucinaţii):_______________________________
_________________________________________________________________
_________________________________________________________________
 Gândirea: →coerenţă/incoerenţă/ritm:__________________________________
_________________________________________________________________
→flux ideativ:____________________________________________
____________________________________________________________________
→ idei obsesivo-fobice:____________________________________
____________________________________________________________________
→ idei dominante:_________________________________________
____________________________________________________________________
→ idei prevalente:_________________________________________
____________________________________________________________________
→idei delirante/expansive/depresive:__________________________
____________________________________________________________________
____________________________________________________________________
 Nivel intelectual:___________________________________________________

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 Limbaj:__________________________________________________________
_________________________________________________________________
 Memoria:_________________________________________________________
_________________________________________________________________
 Instincte: →alimentar:______________________________________________
→sexual:________________________________________________
 Conştiinţa (optuzii, stupoare, delirantă, oniroidă, crepusculară):______________
_________________________________________________________________
_________________________________________________________________

9. RITM NICTEMERAL
 Somn/coşmaruri/mod de trezire:_______________________________________
_________________________________________________________________
_________________________________________________________________