INTERVIU CLINIC

1. ANAMNEZA

Numele:________________________________________________________

Data naşterii:____________________________________________________

Locul naşterii:___________________________________________________

Structura familială:_______________________________________________

Condiţii materiale:________________________________________________

Statut →personal:_________________________________________________
→profesional:_______________________________________________

Căsătorit/necăsătorit:______________________________________________

Copii:___________________________________________________________

Relaţii cu →părinţii:________________________________________________
→soţul/soţia:______________________________________________
→copiii:_________________________________________________

Evenimente de viaţă:_______________________________________________
________________________________________________________________

Relaţii la locul de muncă:___________________________________________

Educaţia în familie:________________________________________________

Grad de instruire:__________________________________________________

2. MOTIVELE INTERNĂRII

Internarea (cu voia lui, urgenţă etc.):___________________________________

Debutul bolii:_____________________________________________________

Prima internare:___________________________________________________

Descrierea simptomelor:____________________________________________
________________________________________________________________

Caracterul bolii:___________________________________________________

Circumstanţele debutului:____________________________________________
_________________________________________________________________

1

EXAMINAREA SOMATICĂ GENERALĂ  Mersul:__________________________________________________________  Motricitatea:______________________________________________________  Sensibilitatea:_____________________________________________________  Coordonare:_______________________________________________________  Reflexe:__________________________________________________________ 6. ANTECEDENTE HEREDO-COLATERALE _______________________________________________________________________ _______________________________________________________________________ __ 4.3. ANTECEDENTE PERSONALE:  Menstruaţia:______________________________________________________  Menopauza:______________________________________________________  Internări cu alte probleme:___________________________________________ _________________________________________________________________  Intervenţii chirurgicale:______________________________________________  Traumatisme:_____________________________________________________ 5. EXAMEN PSIHIATRIC  Ţinuta vestimentară:________________________________________________  Stare de igienă:____________________________________________________  Facies:___________________________________________________________  Privire:___________________________________________________________  Mimică şi pantomimică:_____________________________________________ 7. ORIENTARE SPAŢIO-TEMPORALĂ  Allopsihică:______________________________________________________  Autopsihică:______________________________________________________ 2 .

FUNCŢII PSIHICE:  Afectivitatea (dispoziţii):____________________________________________ _________________________________________________________________ _________________________________________________________________  Voinţa şi activitatea:________________________________________________ _________________________________________________________________ _________________________________________________________________  Atenţia →voluntară:________________________________________________ _________________________________________________________________ →involuntară:______________________________________________ _________________________________________________________________ _  Senzaţii şi percepţii (iluzii şi halucinaţii):_______________________________ _________________________________________________________________ _________________________________________________________________  Gândirea: →coerenţă/incoerenţă/ritm:__________________________________ _________________________________________________________________ →flux ideativ:____________________________________________ ____________________________________________________________________ → idei obsesivo-fobice:____________________________________ ____________________________________________________________________ → idei dominante:_________________________________________ ____________________________________________________________________ → idei prevalente:_________________________________________ ____________________________________________________________________ →idei delirante/expansive/depresive:__________________________ ____________________________________________________________________ ____________________________________________________________________  Nivel intelectual:___________________________________________________ 3 .8.

crepusculară):______________ _________________________________________________________________ _________________________________________________________________ 9. RITM NICTEMERAL  Somn/coşmaruri/mod de trezire:_______________________________________ _________________________________________________________________ _________________________________________________________________ 4 . Limbaj:__________________________________________________________ _________________________________________________________________  Memoria:_________________________________________________________ _________________________________________________________________  Instincte: →alimentar:______________________________________________ →sexual:________________________________________________  Conştiinţa (optuzii. delirantă. oniroidă. stupoare.