I

Formular de Anamneza

I. Date de identificare:

Nume si prenume client:__________________________________Data nasterii:_________________; Frati/surori:_____________________________________

Adresa:_____________________________________________________________________Conditii de viat:_____________________________________________________________

II. Istoric medical al clientului:

Evenimente in timpul nasterii__________________Tip nastere______Scor APGAR_______

Tip alaptare__________________ Boli ale copilariei:__________________Evenimente majore cu risc pentru sanatate din copilarie:______________________________Tip de somatizare_____________________________________________________________

Boli cronice_________________________________________________________________

Diagnostic specific/ data_______________________________________________________

Medicatie specifica___________________________________________________________

Evolutie post-tratamanet_______________________________________________________

Implicatii la nivelul personalitatii________________________________________________

Obiceiuri alimentare:__________________________________________________Schimbri n obiceiul alimentar________de ce__________cnd_________cu ce alimente___________________ Conditii de viat:_____________________________________________________________

Somnul: cantitativ(ore):_________; calitativ:_______________________________________

Tulburari de somn______________________________ de cand________________________ Alte tulburari de comportament__________________________de cand__________________ III Istoricul familiei:

Tip de familie:_______________________________________________________________

Mama- boli cronice __________________________Atitudini fata de copil:__________________________________________________________________________________________

Alte aspecte observate:_________________________________________________________

Tatal:- boli cronice:_________________________Atitudine fata de copil________________

___________________________________________________________________________

Relatia cu bunicii_____________________________________________________________

Istoria relatiei de cuplu mama-tata: _______________________________________________

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ IV. Evenimente relevante din copilaria mica(unde a crescut copilul, cine l-a ingrijit, unde se simtea securizat in gradinita, cum a parcurs anii de gradinita, debutul scolaritatii mici):__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

___________________________________________________________________________ evenimente traumatizante: (din copilaria mica, semne de abuz, blocaje afective, probleme relationale cu mama, cu tatal, cu bunicii)______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________V. Aspecte educationale de suport pentru terapie:

amintiri relevante despre scoala, relatia cu colegii si profesorii:ce simte cand isi aminteste de scoala:________________________________________ motivatii care ghideaza studiul: persoane care sustin studiul:

persoane considerate model:

ce vise are: amintirea care este resursa de eustress: activitati de eustress:

surse de stres: modalitati de manifestare a stresului(psihosomatic):

fobii: obiecte tranzitionale:

semne de anxietate(manifestari psihosomatice, tulburari de personalitate): semne de depresie(corelatie cu episoade depresive din copilarie; istoric genetic al depresiei; evenimente majore traumatice): modalitati de compensare a frustrarilor: modalitati de aparare:

VI. Alte aspecte relevante observate:______________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Data,

Semnatura psiholog clinician,

amintiri relevante despre cum se purtau parintii cu clientul(cu ce parinte se identifica):

Influenta educationala a parintilor:

cum il motivau:

cuvinte cu care il rasfatau:

cuvinte folosite de parinti pentru a-l certa:

modalitati de pedeapsa folosite de parinti(ce respinge la parinti):

reprosuri pentru mama:

reprosuri pentru tata:

existenta Complexului lui Oedip(specificati modul de manifestare):

PAGE 3Cabinet de Consiliere Psihologica: Psiholog clinician Alina Mihaela Munteanu