Data: __ __ / __ __ / __ __ __ __

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):
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Fi de evaluare n tulburarea de panic i agorafobie

Psiholog Chicu Raluca

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: ________________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Fi de evaluare n tulburarea de panic i agorafobie

Psiholog Chicu 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: _______________________________________________________

Fi de evaluare n tulburarea de panic i agorafobie

Psiholog Chicu 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:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Fi de evaluare n tulburarea de panic i agorafobie

Psiholog Chicu Raluca