8/18/2019 Fisa Anamnestica

INSTITUTIA: ___________________________________________________________ FISA ANAMNESTICA 

FUNCTIA: _____________________________________________________________ DATA: ____/_____/_________  

NUME, PRENUME: _________________________________________________________________________________________

C.N.P.:  |__|__|__|__|__|__|__|__|__|__|__|__|__|   MOBIL: |__|__|__|__|__|__|__|__|__|__|  

RISCURI PROFESIONALE : EMA   CMP   RCMP  

STARE CIVILA:  NECASATORIT   CASATORIT  
EDUCATOR / INGRIJITOR   CONDUCATOR AUTO  
CONCUBINAJ   DIVORTAT   VADUV  
POMPIER /  SALVATOR  LUCRU LA INALTIME  
FUNCTIONAR PUBLIC   RADIATII IONIZANTE  
COPII (VARSTA / SEX): _________________________________
FARMACIST   MANEVRANT UTILAJ UZINAL  

PERMIS AUTO: (CATEG./ ANUL) __________________________ ELECTRICIAN   AGENT PAZA / SECURITATE  

SOTUL / SOTIA: PROFESIA ________________________________ STAREA SANATATII ________________________________

MAMA: PROFESIA ________________________________ STAREA SANATATII ________________________________

TATA: PROFESIA ________________________________ STAREA SANATATII ________________________________

STAREA SANATATII DVS.: _______________ MEDICATIE (IN PREZENT): ____________________________________________

SURSE /  MOTIVE DE STRESS: _________________________________________________________________________________

BOLI PSIHICE SUFERITE: ________________________________________________________ INSOMNI: DA  \   NU 

INTERNARI LA PSIHIATRIE: ______________________________________________________ STARI DEPRESIVE: DA  \   NU 

FOBII: ______________________________________________________________________ STARI ANXIOASE: DA  \   NU 

CONSUM ALCOOL (FRECVENTA) _________________________ CONSUM DROGURI (FRECVENTA) ________________________

CONSUM CAFEA (ML / ZI) _______________________________ FUMEZ (TIGARETE / ZI) _________________________________

EVENIMENTE SEMNIFICATIVE ☺ __________________________________________________________________________

(REALIZARI / ESECURI): 
 __________________________________________________________________________
EVOLUTIA PROFESIONALA 

INSTITUTIA: ___________________ |__|__|__|__| - PREZENT  FUNCTIA: ________________________________

INSTITUTIA: ___________________ |__|__|__|__| - |__|__|__|__| FUNCTIA: ________________________________

INSTITUTIA: ___________________ |__|__|__|__| - |__|__|__|__| FUNCTIA: ________________________________

ANTECEDENTE PENALE: _______________________________ ACCIDENTE RUTIERE:_________________________________

CALITATE RELATII DE MUNCA: __________________________ ACCIDENTE DE MUNCA: _______________________________

INTERESE SI PREOCUPARI ACTUALE (ACTIVITATI PREFERATE PENTRU TIMPUL LIBER): ____________________________________ 

DA  \   NU 
Declar ca sunt sanatos, odihnit si nu sunt sub influenta bauturilor alcoolice sau drogurilor.
Declar pe propie raspundere ca nu sunt in evidenta cu boli neurologice, boli psihice,
DA  \   NU 
epilepsie si nu sunt sub tratament pentru boli neuropsihice.

SEMNATURA: _______________________________
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