INTERVIU CLINIC

1. ANAMNEZA
 Numele şi prenumele: _____________________________________________________
 Data naşterii: ____________________________________________________________
 Locul naşterii: ____________________________________________________________
 Structura familială: _______________________________________________________
 Condiţii materiale: ________________________________________________________
 Statut:
- Personal: ____________________________________________________________
- Profesional: __________________________________________________________
 Stare civilă: ______________________________________________________________
 Relaţii cu:
- părinţii: ________________________________________________________________
- fraţii: __________________________________________________________________
 Evenimente de viaţă: ______________________________________________________
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 Relaţii sociale: ___________________________________________________________
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 Educaţie în familie: _______________________________________________________
 Grad de instruire: ________________________________________________________

2. MOTIVELE PREZENTĂRII LA ÎNTÂLNIRE:

 Cu voia lui, urgenţă, etc.: ______________________________________________________
 Descrierea simptomelor: ______________________________________________________
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 Caracterul bolii: _____________________________________________________________
 Circumstanţele debutului: _____________________________________________________
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  ANTECEDENTE HEREDO- COLATERALE:
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3. ANTECEDETE PERSONALE:
 Internări cu alte probleme: _________________________________________________
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 Intervenţii chirurgicale: ____________________________________________________
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 Traumatisme: ____________________________________________________________

4. EXAMINARE SOMATICĂ GENERALĂ:

 Mersul: _________________________________________________________________
 Motricitate: _____________________________________________________________
 Sensibilitate: ____________________________________________________________
 Coordonare: _____________________________________________________________
 Reflexe: _________________________________________________________________

5. EXAMEN PSIHIATRIC:
 Ţinuta vestimentară: ______________________________________________________
 Stare de igienă: __________________________________________________________
 Facies: __________________________________________________________________
 Privire: _________________________________________________________________
 Mimică şi pantomimică: ___________________________________________________

 ORIENTARE SPAŢIO- TEMPORALĂ: __________________________________________

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 6. FUNCŢII PSIHICE:
 Afectivitate (dispoziţii): ____________________________________________________
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 Voinţa şi activitatea: ______________________________________________________

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 Atenţia:
- Voluntară: ___________________________________________________________
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- Involuntară: __________________________________________________________
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 Senzaţii şi percepţii (iluzii şi halucinaţii): ______________________________________

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 Gândirea:
 Coerenţa/ incoerenţa/ ritm: ________________________________________________
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  Flux ideativ: _____________________________________________________________
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 Idei obsesivo- fobice: ______________________________________________________
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 Idei dominante: __________________________________________________________
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 Idei prevalente: __________________________________________________________
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 Idei delirante expansive/ depresive: _________________________________________
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 Nivel intelectual:
 Limbaj (stereotipii / dislalii): ________________________________________________

 Memoria (fixare/ evocare/ amnezii): _________________________________________

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  Instincte:
- Alimentar: ___________________________________________________________
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- Sexual: ______________________________________________________________
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 Conştiinţa: (optuzii/ stupoare/deliranta/oniroida/crepusculară): __________________
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7. RITM NICTEMERAL:
 Somn/ coşmaruri/ mod de trezire): __________________________________________
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