Табачная зависимость у больных алкоголизмом
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ПРИЛОЖЕНИЯ
Приложение 1. Карта исследования.
А. Паспортная часть.
1. Фамилия, имя, отчество_
2.Дата рождения_3 .Возраст_4.Пол_5.Национальность
б.Вероисповедание_7.Адрес:_8.телефон_
9№ истории болезни, амбулаторной карты_
10.Дата поступления(постановки на учёт)_11.Дата выписки_
12..Диагноз основного заболевания в шифре по МКБ_
1.Наследственная отягощенность психическими заболеваниями:_
1.Отец 2.Мать З.Брат 4.Сестра 5 .Дедушка б.Бабушка
5.1 Отца 5.2 Матери 6.1 Отца 6.2 Матери
а. Курение
Ь. Алкоголизм
с.Не установлено
^Наркомания
е.Психопатия
£Суициды
Я.Шизофрения
И.МДП (моно-, би-)
^Эпилепсия
к.Олигофрения
1. Прочее
2. Патология беременности у матери:
1.Не установлено □
2.Патология родов □
3.Асфиксия плода □
4.Применение плодооживляющих методик □
5.Патология в раннем постнатальном периоде □
3. Обследуемый воспитывался:
1.В полной семье □
2.В неполной семье □
3.Родственниками □
4.В приемной семье □
5.В детском доме □
6.Прочее □
4. Отношения между родителями:
1.Ровные (хорошие, удовлетворительные) □
2.Неровные (периодически конфликтные) □
3.Постоянно конфликтные □
4.Нейтральные □
5. Отношение родителей к обследуемому:
1.Гиперопека □
2.Гипоопека □ З.Заботливое □
4.Равнодушное □
5.Неприязненное □
6. Удовлетворённость своим положением в семье:
1.Удовлетворён полностью □
2.Скорее удовлетворён чем неудовлетворён □
3.Скорее неудовлетворён чем удовлетворён □
4.Неудовлетворён □
7. Невротические эпизоды в детстве:
1.Отсутствовали □
2.Страхи □
3.Логоневроз □
4.Тики □
5.Снохождение, сноговорение □
6.Ночной энурез □
7.Реакции протеста □
8.Прочее □
8. Семейный статус:
1.Состоит в браке □
2.Гражданский брак □
3.В разводе □
4.Вдовец(а) □
5.Холост □
9.Семейные отношения:
1.Нормальные □
2.Умеренно конфликтные (напряженные) □
3.Средне конфликтные □
4.Крайне конфликтные □
5.Нейтральные □
10. Наличие детей:
1.Нет □
2.Есть □ (указать сколько цифрой)_
11.Образование:
1.Высшее □
2.Незаконченное высшее □
3.Среднее-специальное □
4.Среднее □
5.Незаконченное среднее □
12.Трудовой стаж (количество лет):_
13.Трудовой статус в настоящее время:
1.Учащийся (дневная форма обучения) □
2.Служащий □
