Peer name 4 rane. (as fe Giitale Female 5 ‘Attending pysicon: i z Cal thas g pan palace padsll Assessment of social - Psycho & Discharge Planning Other, specify A! facilities BL. patient Gato | Data source Stal ee | the initial information about the patient: | A 2 number of wife tiny3! se > Married es4= L Child Gk Desert ats Widowed Je) o Divorce Secondaryss20 intermediate Me Primary 5d | Other s.Al © university ase = | Educational Level labor Heo Housewife U4 Officer Hime Student rofession ae Unemployed or disabled acy dae | POF Street name ‘451 m=! icy tna ads as + Phone Number/ Mobile Jo JA oi, ( ) House number / = ais ) Js ke) Monthiyincome ge s!| Zero income Jéelpsme> Pension yi Monthly salary 44°" > Sources of income As as | Other sources mention. 3l 81 shee Social security ALES! Gas al [ent amount Fk Rene Property | Hoang za | Public house ya 3 ‘Apartment 4+ Villa 342 | ae of housing , | ‘There is no housing os Charitable 525 Roomiizo | YP x ee (Number of rooms 448 |The health status of housing Stas Say Gadi G Medium tsa Good feo 7 lighting I amber offamiy members) SA (aes 1 Femates patient () cel it Unstable Ais xb 0 Stable = General situation ofthe family 5 ol a Social history and evolutionary forthe patient Se PEST) I Mediums Goods before the disease: =) 8 () Bade Mediumiias Good #3 after diseases 20 = ("| onship with those aroundthe patients at ct ee | ~ after disease vai = ‘before the disease =i Ja a edumii=s=n | Goodies | waltz | Medumingeo] Goodies | family (0 Medumii=gsc | Goode o- Medumine go ia | sense Medivmtin 0 Mediums 0 | Good tec | shoo! Sad (7 Mediumiba 0 Mediumik=o | Good tye | friends wine (¢i Pa ar MW = angoulanoi@ Loo) FRO aaciloji9 se Gar Grom nina daall al} dan dy stile (mmo Minty of eaye, usages anadroans behavior ofthe patient/family re ES ‘number of times admitted to hospital ( _) tial Jghs yeas |a v4__]../.. Date of infection sly Sha tai¥ , = iE Yes eaic_| Isthe patient suffers from a disability ==) G Ay tw Ao Fat Go| penal gina | Wind ws0 [No Yo Yes 3 the patient ls smokes Bebo No Yo | Yes sala. | aleoholordrugaddict mea ischarge Plai Coordination with the relevant ahorities on his discharge. “Eee Ai) Meal device WR Ye AIS Accommodation services His health and social condition is stable and can go home “Ta SAD Aik y ae ela ly eal Aang his need for suppor for ‘governmental organization charitable organization oma Toa Saga ae specify Other. Treatment proposed of social ‘Treatment Of environmental ou 5 Gg] Selftreatment i pe lal ae oath | Summary of social treatment and action that has been den ape Social worker FURY laid) eee ea Signature a 003