FIŞA DE EVALUARE PRIMARA

I. Date personale
Numele copilului
________________

Data naşterii________________
Locul naşterii _______________
Adresa
__________________________________________________________________________
Grădiniţa/şcoala ________________
Tatăl _________________
vârsta________________
ocupaţia ______________
Mama________________
vârsta _________________
ocupaţia________________

I. Situaţia familială
Fraţi ________________
Surori ________________
Alţi membri ai familiei care locuiesc cu copilul
__________________________________________________________________________

Condiţii de locuit ____________________________________________________________

Relaţiile între părinţi _________________________________________________________
Relaţiile dintre părinţi şi copil __________________________________________________
Atitudinea părinţilor faţă de problemele copilului ____________________________________
Relaţiile părinţilor cu şcoala ____________________________________________________
Cine se ocupă de educaţia copilului şi cât timp _____________________________________
Metode şi procedee folosite de părinţi în educarea copilului ___________________________
__________________________________________________________________________
__________________________________________________________________________

Antecedente heredo-colaterale (afecţiuni ale membrilor familiei)

__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

III. Antecedente fiziologice

Date despre sarcină:
• felul sarcinii - normală ________________
- toxică ________________

• afecţiuni ale mamei în perioada sarcinii:

- viroze ________________
- pneumonii ________________
- infecţii renale ________________
- disgravidie ______________________________________________________________

• medicaţie şi tratamente în timpul sarcinii _______________________________________

• Rh-ul părinţilor _________________________________________________________

• Naştere:
- la termen ______________
- prematur _______________
- postmatur ______________
- cezariană ______________
- forceps ________________
- placenta praevia ________________
- durata travaliului ________________
• cordon ombilical:
- circulară de cordon ________________
- dublă circulară de cordon ________________
• prezentaţie:
- craniană ________________
- pelviană _________________
- transversală _____________
• scor APGAR ________________
• alte date:
- icter prelungit ________________
- incubator ____________________
- hrănire ______________________
• Vaccinări ____________________

Antecedente patologice:
• boli _____________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
primele simptome ___________________________________________________________
• istoricul bolii ____________________________________________________________
• internări:
- vârsta _________________
- motivul __________________________________________________________________
- unde ____________________________________________________________________
- tratament ________________________________________________________________
_________________________________________________________________________

IV. Dezvoltarea psihomotorie

Repere:
- când a ţinut capul _________________
- când a stat în şezut ________________
- mersul în patru labe ________________
- când a început să meargă ___________
- control sfincterian __________________
- tonusul muscular general ____________________________________________________
- abilităţi normale ___________________________________________________________
- lateralitate ________________
- coordonare _______________

V. Dezvoltarea limbajului
Repere:
- lalaţiunea ____________________
- primele silabe _____________________________________________________________
- primele cuvinte ____________________________________________________________
- primele propoziţii __________________________________________________________
- nivelul vocabularului ________________________________________________________
- înţelegerea limbajului/ limbaj receptiv
__________________________________________________________________________
__________________________________________________________________________
- scrierea
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
- citirea
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
- dificultăţi de pronunţie
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

VI. Stadiul dezvoltării în momentul evaluării

• motricitate
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

• cogniţie
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

• comunicare
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

• socializare
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

• grad de autonomie personală

__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

• situaţia şcolară
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

• diagnostic
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
VII. Consemnări în convorbirile cu părinţii
• Activităţi preferate
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

• Activităţi dezagreate
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

• Jucării preferate
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

• Manifestări de agresivitate, negativism, apatie

__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

• Alte observaţii ale părinţilor

__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

11
VIII. Concluzii, recomandări:
• Nevoile copilului şi recomandarea P.I.P.
Tipul de asistenţă recomandat
• Recomandări speciale:
- consultaţii de specialitate
- recomandări curriculare
IX.