FIŞA DE EVALUARE INDIVIDUALĂ

I. Date personale
Nume şi prenume: ______________________________________________________________
Data şi locul naşterii: ___________________________________________________________
CNP ___/___/___/___/___/___/___/___/___/___/___/___/___/
Stare civilă/Statut juridic ________________________________________________________
Studii: _____________________________, Ocupaţia: _________________________________
Etnia: _____________________________, Religia: __________________________________
Domiciliul: ___________________________________________________________________
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II. Starea de sănătate psiho-fizică

Istoric medical: __________________________________________________________________
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Starea de sănătate prezentă : ________________________________________________________
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Profilul psihologic : _______________________________________________________________
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III. Istoric social

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IV. Aspecte privind mediul de viaţă

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V. Concluzii şi recomandări
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Data : ___________________________
Asistent social : _________________________