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Ime i prezime deteta:__________________________________

Datum roenja:_________________

Datum dolaska________________

Ko upuuje dete:_________________________________________________
Razlog dolaska:________________________________________________________________________
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Kad su poele tegobe:___________________________________________________________________
Opis tegoba sada:______________________________________________________________________
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Perceptivne obmane, sumanuti sadraji:_____________________________________________________
Suicidalne misli:________________________________________________________________________
Hormike funkcije:______________________________________________________________________
Neurotine navike:______________________________________________________________________
Prostorno vremenska orjentacija:__________________________________________________________
Voljno-nagonski dinamizmi:_______________________________________________________________
Strahovi:______________________________________________________________________________
Porodica -Sa kim ivi:__________________________________________________________________
Porodini odnosi:_____________________________________________________________________
Hereditet:_____________________________________________________________________________
Uslovi za ivot:_________________________________________________________________________
kola-Razred i uspeh u koli:____________________________________________________________
Odnos sa nastavnicima:_________________________________________________________________
Ukori, izostanci, da li redovno pohaa kolu:________________________________________________
Socijalni odnosi:______________________________________________________________________
U koli:_____________________________________________________________________________
Van kole:___________________________________________________________________________
Lina anamneza:
Red rodjenja deteta:_____________________________________
Trudnoa:____________________________________________________________________________
Poroaj :__________________________________________________________________________
Apgar skor:___________________________________________________________________________
Kad je prohodao:_______________________________________________________________________
Kad je progovorio:______________________________________________________________________
Bazalne navike:_________________________________________________________________________
Druge bolesti:__________________________________________________________________________
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