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Fisa de anamneza

NUMELE _____________________________ PRENUME

____________________________________
Data nasterii:_________________________________________
Informatii furnizate de :_________________________________
culese de :___________________________________
la data de :__________________________________

I ANTECEDENTE PERSONALE
1. Nasterea : __________________________________________la termen ?
________________________
Durata travaliului _________________________________________
Asfixiere la nastere :__________________________Reanimare
:____________________________________
Nastre prematura :___________________________Cistostomie :_________________icter
:______________
Nastere fara dureri :_______________________________________
Complicatii la nastere :____________________________________
Forceps :_______________________________________________Anestezie
:__________________________
Circulara de cordon :_________________________________________
Hemoragii :_________________________________________________
Interventii cirurgicale la nastere : _______________________________

2. Sarcina :______________________________Rangul
nasterii:_______________________________________

Eclampsie :_________________________________________________
Rubeola :__________________________________________________
Alte boli infectioase :__________________________________________
Intoxicatii medicamentoase :___________________________________
Alcolismul mamei : ___________________________________________
Psihoza sau nevroza
_________________________________________________________________________
____________________________________________________________________________________
_______________
Vomitaturi : ___________________________________________________
Pericole fizice de avort : _________________________________________
Pericole eddocrine de avort :______________________________________
 Travaliu pe timpul sarcinii :________________________________________
 Hemoragii:_________________________________________________
Perioada de intrerupere :________________________________________
3.istoricul dezvoltarii :__________________________________________

Hranirea la san :________________________________________________

biberon : ____________________________________________
intarcare :____________________________________________
greutati de hranire :_____________________________________
Primul dinte :____________________________________________________
Sta asezat : ________________________________ Curatenie
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:________________________________________
Primii pasi :___________________________________Mers
:__________________________________________
Primele cuvinte :__________________________________Primele fraze
:_________________________________
Tulburari ale pronuntiei
:_________________________________________________________________________
Se imbraca singur :_____________________Incheierea sireturilor de la
incaltaminte:________________________
Pubertate
:____________________________________________________________________________________
Dreptaci
:______________________________________________
Stangaci
:_____________________________________________

II ANTECEDENTE PATOLOGICE PERSONALE

Rujeola
:__________________________________________________________________________________
Varicela
:____________________________________________________________________________________
_
Tuse convulsiva
:______________________________________________________________________________
Scarlatina
:___________________________________________________________________________________
(sa se noteze la ce varsta si mai ales complicatile )
Alte boli infectioase
:___________________________________________________________________________

____________________________________________________________________________________
_________
Otite -
mastoidite:___________________________________________________________________________
___

____________________________________________________________________________________
__________

____________________________________________________________________________________
__________
Toxicitate
:___________________________________________________________________________________
Sindrom meningo -encefalic
:_____________________________________________________________________

____________________________________________________________________________________
___________

(Sa nu se uite complicatiile vaccinale )

Convulsii:____________________________________________________________________________
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__________
Crize convulsise cu caracter comitial
:______________________________________________________________

(Data aparitiei ,ritm,descriere )

____________________________________________________________________________________
______________

____________________________________________________________________________________
______________
Alte boli neurologice
:_____________________________________________________________________________
Traumatisme craniene
:____________________________________________________________________________

____________________________________________________________________________________
______________
Iterventii chirurgicale
:_____________________________________________________________________________

____________________________________________________________________________________
______________
Examene si tratamente anterioare
:__________________________________________________________________

____________________________________________________________________________________
_______________

____________________________________________________________________________________
_______________
Sederi in spital
:__________________________________________________________________________________
Plasari :la cresa
:________________________________________________________________________________
la pensiune
:______________________________________________________________________________
(Varsta si in I.M.P.
:_____________________________________________________________________________
durata )

III . ISTORICUL SCOLARITATII

Cresa
:____________________________________________________________________________________
______
Gradinita de
copii:________________________________________________________________________________
_
Scoala primara
:___________________________________________________________________________________
Clase de perfectionare
:_____________________________________________________________________________
Ucenicie
:____________________________________________________________________________________
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____

IV.ANTECEDENTE FAMILIALE

1.Tata :-Varsta
:____________________________________________________________________________________
-Starea sanatatii pe timpul conceptiei
:___________________________________________________________
-Starea sanatatii dupa aceea
:__________________________________________________________________
-Nivelul scolar atins si pregatierea profesionala
:____________________________________________________

____________________________________________________________________________________
______________
-Profesiunea
:________________________________________________________________________________
Bunicii din partea
tatalui____________________________________________________________________________
Mama; Sanatate
:_____________________________________________________________________________
Nivel
:________________________________________________________________________________
Profesie
:____________________________________________________________________________
Tata : Sanatate
:_____________________________________________________________________________
Nivel
:_________________________________________________________________________________
Profesie
:______________________________________________________________________________
2.Mama:-Varsta, la nasterea
copilului:________________________________________________________________
-Starea sanatatii , inainte de nasterea copiluiui
:_________________________________________________
- Starea sanatatii dupa aceea
:_______________________________________________________________

____________________________________________________________________________________
________________
Bunici din partea mamei
:__________________________________________________________________________
Mama :Sanatate
:_______________________________________________________________________________
Nivel
:___________________________________________________________________________________
Profesie
:________________________________________________________________________________
Tatal : Sanatate
:________________________________________________________________________________

Nivel:________________________________________________________________________________
____
Profesie
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:_________________________________________________________________________________
Frati si surori ai subiectului(varsta ,starea sanatatii ,niveluil scolar sau profesional ,eventuala
scolarizare in clasa de profesionare s.a )
____________________________________________________________________________________
__________
____________________________________________________________________________________
_________________________
____________________________________________________________________________________
________________________
____________________________________________________________________________________
____________________________________________________________________________________
__________________________________________________
Alte informatii referitoare la antecedente
:____________________________________________________________________________________
________________________
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____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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_______________
____________________________________________________________________________________
________________________-

V.FACTORI AFECTIVI
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_________________________________________
V.I FACTORI SOCIALI

Locuinta:_____________________________________________________________________________
_______________
____________________________________________________________________________________
____________________________________________________________________________________
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____________________________________________________________________________________
_______________________________________

VII.CONCLUZII

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