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  ANAMNEZA – INTERVIU CLINIC

DATE PERSONALE SI SOCIALE:

 Numele si prenumele pacientului: ________________________________ Data si locul nasterii: Ziua_____ Luna____________ Anul_____

Localitatea: _____________________________ Judetul: ______________________________________________ CNP:

Domiciliul:

Localitatea:__________________Strada:_______________ Nr.:___ Bl.___ Sc.___ Apt.___Telef.:Fi:______________!o"il: ______________ 

Locul de munca:

#elatii la locul de munca:

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Tipul familiei de pro$enienta:

Tip familie:______________________alcatuita din__________________________________________________________________________ 

Parinti:

  Tata: ___________________________________________________________________________________________________________ 

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  !ama: __________________________________________________________________________________________________________ 

  #elatiile din trecut cu parintii: ________________________________________________________________________________________ 

  #elatiile actuale cu parintii: __________________________________________________________________________________________ 

Frati: _______________________________________________________________________________________________________________ 

  #elatiile din trecut cu fratii: __________________________________________________________________________________________ 

  #elatiile actuale cu fratii: ____________________________________________________________________________________________ 

Surori: ______________________________________________________________________________________________________________ 

  #elatiile din trecut cu surorile: _______________________________________________________________________________________ 

  #elatiile actuale cu surorile: _________________________________________________________________________________________ 

Stare maritala: __________________ Numele sotului %sotiei&___________________ 'arsta _______ Profesia ___________________________ 

#elatia cu sotul %sotia&:

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Copii:_______________________________________________________________________________________________________________ 

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#elatia cu copiii: ______________________________________________________________________________________________________ 

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VENIT PROPRIU: ___________________________________________________________________________________________________ 

VENIT FAMILIAL: __________________________________________________________________________________________________ 

ANTECEDENTE PERSONALE:

 Nr. internari in spital ____ !oti$ele internarii %dia(nostic& ____________________________________________________________________ 

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 Nr. internari in spitale de psi)iatrie ____ Dia(nostic __________________________________________________________________________ 

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ANTECEDENTE COLATERALE (rude grad I, a se spe!"!a d#ar $#%!%e &!'a%e, 'eur#%#g!e)

Par!'!:

  Tata: ___________________________________________________________________________________________________________ 

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  !ama: _________________________________________________________________________________________________________ 

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  Frati: __________________________________________________________________________________________________________ 

 ____________________________________________________________________________________________________________________ 

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 ____________________________________________________________________________________________________________________ 

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  Surori: ________________________________________________________________________________________________________ 

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*#$$+ur!: __________________________________________________________________________________________________________ 

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ACUZE PREZENTE: ________________________________________________________________________________________________ 

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ANALIZE MEDICALE EFECTUATE:

*n ultimele trei luni: ___________________________________________________________________________________________________ 

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*n ultimele sase luni: ___________________________________________________________________________________________________ 

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E-a%uare ps!.!a e"euaa _______ Daa e"euar!! ____________ D!ag'#s! __________________________________________________ 

Med!u% are a pus d!ag'#s!u% ________________________________________________________________________________________ 

I's!u!a ___________________________________________________________________________________________________________ 

E-a%uare ps!.#%#g!a e"euaa _________ Daa e"euar!! _____________ D!ag'#s! ___________________________________________ 

Ps!.#%#g e/a&!'a#r __________________________________________________________________________________________________ 

I's!u!a ___________________________________________________________________________________________________________ 

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RECOMANDARI:

01 A'a%!2e &ed!a%e

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31 Reg!& a%!&e'ar

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