FI DE CUNOATERE

FI DE CUNOATERE

Chestionar multimodal al istoriei vieii

(ARNOLD LAZARUS)

Scopul acestui chestionar este obinerea unui cadru comprehensiv / cuprinztor asupra problemelor dvs. pentru a oferi posibilitatea unei abordri mai directe a acestora. Completnd acest chestionar ct mai sincer i detaliat, vei facilita procesul de cunoatere. Suntei rugai s completai rspunsurile la aceste ntrebri de rutin n loc s folosii timpul real de consultaie.Este de neles dac v preocup ce se ntmpl cu informaiile despre dvs.,pentru c multe sau aproape toate aceste informaii sunt n cel mai nalt grad personale. Aceste fie sunt strict confideniale.

Nici o alt persoan nu are acces la aceste fie fr permisiunrea dvs. Dac nu dorii s rspundei la unele ntrebri, v rugm s scriei :,, nu doresc s rspund.

I. Informaii generale

Nume:_________________________________________________

Adres:________________________________________________

Numere de telefon: ______________________________________

Vrsta: Ocupaia: Sex:

De cine ai fost trimis:___________________________________

____________________________________

Statutul marital (ncercuii):______________________________

Singur Logodit Cstorit

Separat Divorat Vduv

Recstorit (de cte ori)_________

Triesc (locuiesc) mpreun cu cineva____________________________

Locuiesc n: cas, hotel, camer,apartament

Data completrii______________________

II. Descrierea problemelor prezentate

Descriei cu cuvintele dumneavoastr problemele dvs. principale:

Pe scala de mai jos apreciai severitatea problemei ( problemelor) dvs.:

Uor moderat foarte severe extrem de severe total invalidante

suprtoare suprtoare

Cnd au nceput probleme dvs.? ( oferii date)

V rugm descriei evenimentele semnificative care au avut loc atunci sau au avut loc ncepnd de atunci, care ar putea fi legate de apariia sau meninerea problemelor dvs.

Ce soluii la probleme s-au dovedit mai utile? _____________________________________

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Ai mai primit asisten psihologic pentru problemele dvs.? Dac da, v rugm specificai numele specialistului, tipul interveniei, durata i rezultatele:

__________________________________________________________________________

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III. Istorie personal i social

Data naterii________________locul naterii___________________________

Fraii: numrul frailor________vrsta frailor___________________________

Numrul surorilor_______vrsta surorilor_________________________

Tatl: n via________vrsta actual_______________

Ocupaia__________________starea de sntate___________________________

Decedat________la ce vrsta _____data decesului___________________________

Ce vrs aveai atunci?______________________

Cauza morii__________________________________________________________

Mama: n via________vrsta actual_______________

Ocupaia__________________starea de sntate__________________________

Decedat________la ce vrsta _____ data decesului__________________________

Ce vrs aveai atunci?______________________

Cauza morii__________________________________________________________

Religia:n copilrie_____________________la maturitate_________________________

Educaia: (care este ultimul nivel absolvit)_______________________________________

Puncte forte i puncte slabe n coal:

Subliniai ceea ce se potrivete copilriei/ adolescenei dvs.:

Copilrie fericit probleme medicale

Copilrie nefericit probleme colare

Probleme legale probleme familiale

Probleme educaionale convingeri religioase puternice

Probleme comportamentale abuz de drog

Abuz de alcool altele_______________________________

Ce fel de munc desfurai acum?( ocupaia)____________________________________

Locul____________________________________________________________________

Ce fel de slujbe ai avut n trecut?______________________________________________

Munca actual v satisface? dac nu, v rugm s explicai

Care este venitul lunar al familiei?_____________________________________________

Care sunt cheltuielile pentru existen?_________________________________________

Care au fost abilitile dvs. n trecut?___________________________________________

Care sunt abilitile dvs. actuale?______________________________________________

Care este nlimea dvs.?__________Care este greutatea dvs.?____________________

Ai mai fost spitalizat pentru probleme psihiatrice?

Da ( detalii)______________________________________________________

_________________________________________________________________________

Nu

Avei medic de familie?

Da ( nume, nr. de telefon)___________________________________________

Nu

Ai avut tentative suicidare?

Da(detalii context, consecine)_______________________________________

_________________________________________________________________________

Nu

Sufer cineva din familia dvs. de: alcoolism_____________________________________

depresie______________________________________

epilepsie______________________________________

orice altceva care poate fi considerat,,tulburare mental? _________________________

_________________________________________________________________________

A avut / comis vreo rud tentativa de suicid?_____________________________________

A avut / are vreo rud probleme cu legea?_______________________________________

Analiza, pe modaliti, a problemelor dvs. actuale

Seciunea urmtoare este conceput pentru a v ajuta s v descriei problemele curente n detaliu i pentru a le identifica pe cele care ar putea trece neobservate. Aceasta ne va permite s concepem un program de asistare cuprinztor i adaptat nevoilor dvs. specifice.

1. Comportament

Subliniai fiecare din comportamentele urmtoare care v caracterizeaz:

Supraalimentaie retragere

Consum de droguri ticuri nervoase

Vom dificulti de concentrare

Comportament ciudat tulburri de somn

Consum prea mare de butur evitare fobic

Munc prea mult / grea incapacitate de a desfura un anumit

Amnare tip de munc( mutri frecvente )

Reacii impulsive insomnie

Pierderea controlului lene

Asumare a prea multor riscuri probleme de alimentaie

Tentative suicidare comportament agresiv

Compromisuri plns

Fumat

Izbucniri de furie ( ieit din srite)

Exist comportamente, aciuni sau obiceiuri pe care ai dori s le schimbai?____________

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Care sunt talentele/ aptitudinile/ abilitile cu care v mndrii? _____________________

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Ce ai vrea s facei mai mult?________________________________________________

Ce ai vrea s facei mai puin?_______________________________________________

Ce ai vrea s ncepei s facei?______________________________________________

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Ce ai vrea s ncetai s mai facei? ___________________________________________

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Cum v petrecei timpul liber?________________________________________________

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n compania cui?(detalii anturaj) _____________________________________________

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V meninei ocupat n mod compulsiv fcnd un ir nesfrit de activiti nesemnificative?____________________________________________________________________________________________________________________________________

2. Sentimente

Subliniai fiecare din sentimentele urmtoare care vi se potrivesc ( pe care le resimii) adesea:

furios energic plin de speran mulumit

plictisit invidios relaxat stimulat

suprat vinovat gelos optimist

deprimat fericit nefericit tensionat

anxios conflictual trist altele

temtor plin de regrete fr odihn

panicat lipsit de speran singur

Listai principalele frici/ temeri ale dvs.:

1._______________________________________________________

2._______________________________________________________

3._______________________________________________________

4._______________________________________________________

5._______________________________________________________

Care sunt sentimentele pe care le ncercai cel mai des?____________________________

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Ce sentimente / emoii ai vrea s trii mai puin des?_____________________________

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Enumerai cteva din sentimentele/ emoiile pozitive pe care le-ai trit de curnd?_______

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Cnd suntei cel mai adesea pe cale s v pierdei controlul asupra sentimentelor / emoiilor dvs.?____________________________________________________________

Descriei o situaie semnificativ pentru acest lucru _______________________________

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Descriei situaiile care v fac s v simii calm, relaxat ___________________________

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V rugm s completai:

Dac v-a spune ce simt acum ________________________________________________

Unul din lucrurile de care m simt mndru este ___________________________________

Unul din lucrurile de care m simt vinovat este ___________________________________

Sunt cel mai fericit cnd_____________________________________________________

Unul din lucrurile care m supr cel mai tare este ________________________________

Dac nu mi-ar fi team s fiu eu nsumi, a putea s _______________________________

Dac m supr pe tine _______________________________________________________

Ce fel de lucruri recreative sau hobby-uri v fac plcere, v relaxeaz? _______________

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Avei dificulti s v relaxai / odihnii / distrai n weekend-uri i vacane? Dac da, v rugm s explicai_________________________________________________________

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3. Senzaii fizice

Subliniai senzaiile pe care le resimii adesea:

Dureri de cap deranj stomacal probleme de piele

Ameeal ticuri gura uscat

Palpitaii oboseal mncrimi sau arsuri de piele

Spasme musculare contracii musculare dureri de piept

Tensiune dureri de spate bti rapide de inim

Tulburri sexuale tremurturi neplcerea de a fi atins

Incapacitate de relaxare momente de lein/slbiciune

Tulburri intestinale zgomote auzite transpiraie excesiv

Furnicturi ochi apoi tulburri de vedere

iuituri n urechi probleme de auz amoreal

4. Imagini

Subliniai fiecare din elementele care v caracterizeaz:

Imagini sexuale plcute imagini sexuale neplcute

Imagini de neajutorare imagini de singurtate imagini de a fi iubit

Imagini agresive imagini de seducie

Verificai care din urmtoarele vi se potrivesc:

M vd pe mine nsumi ( m imaginez) ca:

Fiind lovit fiind brfit fiind ridiculizat

Neputnd s fac fa lovind pe alii fcnd promisiuni

Avnd succes fiind responsabil altele________________

Pierzndu-mi controlul eund _____________________

Fiind urmrit fiind prins n curs

Ce imagine v vine n minte cel mai des? _______________________________________

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Descriei o imagine, un tablou mental sau o fantezie foarte plcut ___________________

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Descriei o imagine, un tablou mental sau o fantezie foarte neplcut _________________

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Descriei imaginea dvs.despre un loc complet sigur ________________________________

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5. Gnduri

Subliniai fiecare din urmtoarele gnduri care vi se potrivesc:

- Sunt lipsit de valoare, un nimeni, inutil i/ sau nedemn de a fi iubit

- Sunt neatrgtor, incompetent, stupid i/ sau indezirabil

- Sunt ru, nebun, degenerat i/ sau deviant

- Viaa este goal, un pustiu, nu este nimic spre care s caui s te ndrepi ( n viitor)

- Fac prea multe greeli, nu fac nimic corect, bine

Subliniai fiecare din urmtoarele cuvinte pe care le-ai putea utiliza pentru a v descrie:

Inteligent degenerat incompetent

ncreztor moral cu gnduri oribile

Meritoriu (valoros) atent conflictual

Ambiios un deviant cu dificulti de concentrare

Sensibil neatrgtor cu probleme de memorie

Loial nedemn de a fi iubit atrgtor

De ncredere inadecvat nu pot lua decizii

Plin de regrete confuz cu idei suicidare

Lipsit de valoare urt perseverent

Un nimeni prost ncpnat

Inutil stupid bun sim al umorului

Ru naiv muncitor

Nebun onest

Care considerai c este cel mai iraional gnd (idei pe care le avei)? ________________

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________________________________________________________________________

Suntei deranjat de gnduri care revin mereu? ___________________________________

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Pentru fiecare din itemii urmtori, v rugm ncercuii numrul care reflect cel mai fidel opiniile dvs.:

1.dezacord 2.dezacord 3. neutru 4. acord 5. acord

puternic puternic

a) Ar trebui s nu fac greeli a) 1. 2. 3. 4. 5.

b) Trebuie s fiu bun n tot ce fac b) 1. 2. 3. 4. 5.

c) Cnd nu tiu, ar trebui s pretind c tiu c) 1. 2. 3. 4. 5.

d) Ar trebui s nu dezvlui informaii personale d) 1. 2. 3. 4. 5.

e) Sunt o victim a circumstanelor e) 1. 2. 3. 4. 5.

f) Viaa mea este controlat de fore exterioare f) 1. 2. 3. 4. 5.

g) Ali oameni sunt mai fericii dect mine g) 1. 2. 3. 4. 5.

h) Este foarte important s-i mulumeti pe ceilali h) 1. 2. 3. 4. 5.

i) Joac singur; nu-i asuma nici un fel de riscuri i) 1. 2. 3. 4. 5.

j) Nu merit s fiu fericit j) 1. 2. 3. 4. 5.

k) Dac mi ignor problemele, ele vor disprea k) 1. 2. 3. 4. 5.

l) Este responsabilitatea mea s-i fac pe ceilali oameni fericii l) 1. 2. 3. 4. 5.

m) Trebuie s tind/ s m strduiesc spre perfeciune m) 1. 2. 3. 4. 5.

n) La baz sunt dou moduri de a face lucrurile : modul bun n) 1. 2. 3. 4. 5.

corect i modul prost, greit

V rugm s completai urmtoarele:

Sunt o persoan care _______________________________________________________

Toat viaa mea ___________________________________________________________

nc de cnd eram copil _____________________________________________________

Este greu pentru mine s admit _______________________________________________

Unul din lucrurile pe care nu le pot ierta este ____________________________________

Cnd i faci probleme ______________________________________________________

Lucrul ru cnd creti mare este _______________________________________________

Unul din modurile n care a putea s m ajut , dar nu o fac este ______________________

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6. Relaiile interpersonale

A. Familia de origine

1. Dac nu ai fost crescut de prini, cine v-a crescut i ntre ce ani? ______________________________________________________________________________

2. Dai o descriere a personalitii tatlui ( sau a substitutului tatlui) i a atitudinii lui ( prezente i trecute) fa de dvs. __________________________________

______________________________________________________________________________

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3. Dai o descriere a personalitii mamei ( sau a substitutei mamei ) i a atitudinii ei ( prezente i trecute) fa de dvs. __________________________________

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4. n ce moduri ai fost disciplinat ( pedepsit) de prini cnd erai copil?

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5. Relatai o impresie asupra atmosferei casei dvs. ( casa n care ai crescut). Menionai starea de compatibilitate dintre prini i dintre prini i copii. ___________________

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6. Puteai s avei ncredere/ s v confesai prinilor dvs.? _______________________________________________________________________________

7. V nelegeau prinii dvs.? ________________________________________

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8. n fond, v-ai simit iubit i respectat de prini? ______________________________________________________________________________ ______________________________________________________________________________

9. Dac avei un printe vitreg, precizai vrsta la care printele s-a recstorit

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10. S-a amestecat vreodat cineva ( prini, rude, prieteni) n mariajul sau munca dvs., etc.? _____________________________________________________________________

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11. Care sunt cei mai apropiai oameni din viaa dvs.? ______________________

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B. Prietenii

1. V facei prietenii cu uurin________________________________________

2. i pstrai?_______________________________________________________

3. Ai fost vreodat terorizat sau ironizat dur?____________________________

4. Descriei o relaie care v ofer:

Bucurie __________________________________________________________________

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Suprare

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5. Notai msura n care v simii n general confortabil i relaxat n situaiile sociale ( ncercuii):

Foarte relaxat relativ confortabil relativ inconfortabil foarte anxios

6. n general, v exprimai sentimentele, opiniile sau dorinele ntr-un mod deschis i adecvat?_______________________________________________________

Descriei indivizii fa de care ( sau ntrebrile n care ) avei dificulti s fii asertivi. ____________________________________________________________

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7. Avei unul sau mai muli prieteni cu care s v simii confortabil, s v mprtii cele mai intime gnduri sau sentimente? ________________________________________________________________

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C. Mariaj

1. De ct timp v cunoteai soia / soul nainte de a v logodi?

__________________________________________________________________

2. Ct timp ai fost cstorit? _________________________________________

3. De ct timp suntei cstorit? _______________________________________

4. Care este vrsta soiei/ soului dvs.? __________________________________

5. Care este ocupaia soiei/ soului dvs.?________________________________

6. Descriei personalitatea soiei / soului dvs. _____________________________

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7. n ce arii suntei compatibili? ______________________________________

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8. n ce arii suntei incompatibili? ______________________________________

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9. Cum v nelegei cu rudele dvs. prin alian ( socrii, cumnai,etc.)? ________________________________________________________________

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10. Ci copii avei? ____________Nume ________________________________

_____________________________Vrsta ________________________________

11. Prezint vreunul dintre ei probleme speciale? ___________________________

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D. Relaii sexuale

1. Descriei atitudinea prinilor dvs. fa de sex. Se discuta despre sex acas?

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2. Cnd i unde ai obinut primele informaii despre sex?

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3. Cnd ai devenit prima dat contient de propriile impulsuri sexuale?

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4. Ai trit vreodat sentimente de anxietate sau vinovie provocate de sex sau masturbare? Dac da, v rugm s explicai_____________________________

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5. Detalii relevante privind prime experien sexual sau cele ulterioare ________________________________________________________________

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6. Viaa dvs. sexual prezent este satisfctoare? Dac nu, v rugm explicai

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7. Oferii informaii despre orice reacie sau relaie homosexual

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8. V rugm notai orice problem / preocupare sexual nediscutat mai sus

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E. Alte relaii

1. Sunt probleme n relaiile cu oamenii la serviciu? Dac da, v rugm descriei

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2. V rugm completai urmtoarele:

a) unul din modurile n care oamenii m rnesc este _____________________________________________________________________________________________________________________________________

b) a putea s ochez prin________________________________________________

c) o mam ar trebui _____________________________________________________

d) un tat ar trebui ______________________________________________________

e) un prieten adevrat ar trebui ____________________________________________

3. Dai o scurt descriere a dvs. aa cum ai fi descris de:

a) soia/ soul dvs._______________________________________________________

b) cel mai bun prieten ____________________________________________________

c) cineva care v agreaz _________________________________________________

d) cineva care nu v agreaz ______________________________________________

4. Suntei n mod obinuit afectat de faptul de a fi respins n trecut sau de pierderea unei relaii de prietenie/ colegialitate?Dac da, v rugm explicai__________

___________________________________________________________________ ______________________________________________________________________________________________________________________________________

5. Suntei n mod obinuit afectat de faptul de a fi respins n trecut sau de pierderea unei relaii de dragoste?Dac da, v rugm explicai_____________

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F. Factorii biologici

Avei preocupri curente legate de sntatea dvs. fizic? V rugm explicai ________________________________________________________________________

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V rugm enumerai medicamentele pe care le luai n mod curent sau pe care le-ai luat n ultimele 6 luni ( inclusiv aspirin, pilule anticoncepionale sau medicamente prescrise sau autoadministrate)

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Avei n fiecare zi trei mese echilibrate? ________________________________________

Dac nu, v rugm explicai __________________________________________________

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Facei n mod regulat exerciii fizice? Dac da, ce tip i ct de des?

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Verificai ( ncercuii ) care din urmtoarele v caracterizeaz ( vi se potrivesc):

Marijuana stimulante insomnie

Tranchilizante halucinogene( LSD,etc.) dureri de cap

Sedative diaree dureri de spate

Aspirin constipaie treziri timpurii dimineaa

Cocain alergii somn sntos( potrivit)

Analgezice pusee de tensiune mncat excesiv

Alcool probleme cardiace apetit srac

Cafea greuri mese de proast calitate

igri vom

Subliniai oricare din urmtoarele care se aplic membrilor familiei dvs.: boli tiroidiene, boli de rinichi , astm, boli neurologice, boli infecioase, diabet, cancer, boli gastrointestinale, probleme de prostst, glaucom, epilepsie, altele ____________________

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Ai avut vreodat boli ale corpului sau pierderi de contiin? V rugm dai detalii

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V rugm descriei orice operaie chirurgical pe care ai avut-o( dai date)

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Descriei orice fel de accidente sau traumatisme de care ai suferit ( dai date)

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Istoria etapelor

V rugm subliniai (scriei) cele mai semnificative amintiri sau experiene de la urmtoarele vrste:

0-5______________________________________________________________________

6-11_____________________________________________________________________

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11-15 ____________________________________________________________________

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16-20 ____________________________________________________________________

___________________________________________________________________________________________________________________________________________________________________________________________________________________________21-25 ___________________________________________________________________

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26-30 ____________________________________________________________________

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31-35 ____________________________________________________________________

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__________________________________________________________________________________________________________________________________________________36-40 ____________________________________________________________________

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41-45 ____________________________________________________________________

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46-50 ____________________________________________________________________

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51-55 ___________________________________________________________________

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56-60 ____________________________________________________________________

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61-65 ____________________________________________________________________

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