FISA de EVALUARE Panica Si Agorafobie
4
FISA DE EVALUARE 1. Numele pacientului: ____________________________________________________________ 2. Data nasterii: __ __ / __ __ / __ __ __ __ 3. Date de contact: Adresa: ______________________________________________________________________ Telefon: _____________________________________________________________________ Email: _______________________________________________________________________ 4. Nivel de educatie: ______________________________________________________________ 5. Locuieste cu: __________________________________________________________________ 6. Stare civila: ___________________________________________________________________ 7. Probleme de sanatate psihica in familie (precizati gradul de rudenie si natura problemei): ____________________________________________________________________________ 8. Motivul adresarii (in cuvintele pacientului): _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ 9. Istoricul tulburarii (momentul aparitiei, contextul de viata, descrierea primului AP, reactia celor apropiati, tratamente sau metode de ameliorare incercate pana in prezent, etc): _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Fișă de evaluare în tulburarea de panică și agorafobie Psiholog Chișcu Raluca Data: __ __ / __ __ / __ __ __ __
description
FISA de EVALUARE Panica Si Agorafobie
Transcript of FISA de EVALUARE Panica Si Agorafobie
FISA DE EVALUARE
1. Numele pacientului: ____________________________________________________________
2. Data nasterii: __ __ / __ __ / __ __ __ __
3. Date de contact:
Adresa: ______________________________________________________________________
Telefon: _____________________________________________________________________
Email: _______________________________________________________________________
4. Nivel de educatie: ______________________________________________________________
5. Locuieste cu: __________________________________________________________________
6. Stare civila: ___________________________________________________________________
7. Probleme de sanatate psihica in familie (precizati gradul de rudenie si natura problemei):
____________________________________________________________________________
8. Motivul adresarii (in cuvintele pacientului):
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
9. Istoricul tulburarii (momentul aparitiei, contextul de viata, descrierea primului AP, reactia celor
apropiati, tratamente sau metode de ameliorare incercate pana in prezent, etc):
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Fișă de evaluare în tulburarea de panică și agorafobie Psiholog Chișcu Raluca
Data: __ __ / __ __ / __ __ __ __
In prezent:
10. Pacientul/ a se afla sub tratament medicamentos? Da □ Nu □ Daca da, va rugam precizati numele medicamentelor si schema de tratament:
Nume medicament Dimineata Pranz Seara
Numele medicului care a prescris medicatia si datele de contact:
____________________________________________________________________________________
11. Pacientul/ a sufera de alte boli sau a suferit recent de o boala sau o interventie chirurgicala? Daca da,
precizati: ________________________________________________________________________
12. Descrierea simptomelor fiziologice: care sunt simptomele fiziologice care il / o deranjeaza pe
pacient/a?
a. _____________________________ e.____________________________
b. _____________________________ f. ____________________________
c. _____________________________ g. ____________________________
d. _____________________________ h. ____________________________
13. Descrierea comportamentelor de asigurare si evitare.
A. Care sunt locurile sau activitatile pe care pacientul / a le evita?
a. Mers cu metroul, autobuzul sau tramvaiul g. Mers cu liftul
b. Iesit singur/a din casa h. Mers la restaurant
c. Mers la piata / supermarket / i. Mers la toalete publice
alte locuri aglomerate j. Activitate fizica
d. Trecut prin pasaje k. Activitate sexuala
e. Mers cu masina l. Ramas singur/a in casa
f. Alcool / cafea k. Iesit din oras
Altele: ________________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Fișă de evaluare în tulburarea de panică și agorafobie Psiholog Chișcu Raluca
B. Care sunt lucrurile / activitatile pe care pacientul le face in plus?
a. Sticla cu apa / suc / dulce e. Cautat pe internet informatii
b. Medicatie in geanta / buzunar f. Reviste, forumuri
(inclusiv calciu, etc) g. Repetarea unor ganduri pozitive
c. Medicamente la nevoie h. Mers la biserica / rugaciuni
(precizati: _______________________ i. Telefon cu numere de urgenta
_______________________________ ) j. Verificarea corpului
d. Persoana de siguranta
Altele: __________________________________________________________________________
________________________________________________________________________________
14. Alte mecanisme de mentinere (ex. context social, familial, profesional, beneficii secundare, etc;
descrieti)
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
15. Care sunt cele trei locuri / situatii de care pacientul / a se teme cel mai mult?
a. __________________________________________________________
b. __________________________________________________________
c. __________________________________________________________
16. Ce crede pacientul /a ca i s-ar putea intampla?
a. Sa lesin si sa cad
b. Sa mi se faca rau si sa mor (precizati: atac de cord, atac cerebral, sufocare,
altele_____________________________________________________ )
c. Sa imi pierd controlul si sa ma fac de ras
Altele: _______________________________________________________
Fișă de evaluare în tulburarea de panică și agorafobie Psiholog Chișcu Raluca
17. Ce crede pacientul/a despre problema sa?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
18. Cum crede pacientul /a ca s-ar putea rezolva problema sa?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
19. Care sunt asteptarile si obiectivele pacientului privind terapia? Ce crede ca se va intampla in terapie?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
20. Alte precizari:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Fișă de evaluare în tulburarea de panică și agorafobie Psiholog Chișcu Raluca
