Documente Academic
Documente Profesional
Documente Cultură
moderat
suprtoare
foarte severe
extrem de severe
total invalidante
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.
Copilrie fericit
Copilrie nefericit
Probleme legale
Probleme educaionale
Probleme comportamentale
Abuz de alcool
probleme medicale
probleme colare
probleme familiale
convingeri religioase puternice
abuz de drog
altele_______________________________
retragere
ticuri nervoase
dificulti de concentrare
tulburri de somn
evitare fobic
incapacitate de a desfura un anumit
tip de munc( mutri frecvente )
insomnie
lene
probleme de alimentaie
comportament agresiv
plns
energic
invidios
plin de speran
relaxat
mulumit
stimulat
suprat
deprimat
anxios
temtor
panicat
vinovat
fericit
conflictual
plin de regrete
lipsit de speran
gelos
nefericit
trist
fr odihn
singur
optimist
tensionat
altele
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3. Senzaii fizice
Subliniai senzaiile pe care le resimii adesea :
Dureri de cap
Ameeal
Palpitaii
Spasme musculare
Tensiune
Tulburri sexuale
Incapacitate de relaxare
Tulburri intestinale
Furnicturi
iuituri n urechi
deranj stomacal
probleme de piele
ticuri
gura uscat
oboseal
mncrimi sau arsuri de piele
contracii musculare
dureri de piept
dureri de spate
bti rapide de inim
tremurturi
neplcerea de a fi atins
momente de lein/slbiciune
zgomote auzite
transpiraie excesiv
ochi apoi
tulburri de vedere
probleme de auz
amoreal
4. Imagini
Subliniai fiecare din elementele care v caracterizeaz :
Imagini sexuale plcute
Imagini de neajutorare
Imagini agresive
imagini de a fi iubit
fiind brfit
lovind pe alii
fiind responsabil
eund
fiind prins n curs
fiind ridiculizat
fcnd promisiuni
altele________________
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degenerat
moral
atent
un deviant
neatrgtor
nedemn de a fi iubit
inadecvat
confuz
urt
prost
stupid
naiv
onest
incompetent
cu gnduri oribile
conflictual
cu dificulti de concentrare
cu probleme de memorie
atrgtor
nu pot lua decizii
cu idei suicidare
perseverent
ncpnat
bun sim al umorului
muncitor
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
puternic
a)
b)
c)
d)
e)
2.dezacord
3. neutru
4. acord
5. acord
puternic
a) 1. 2.
3.
4.
5.
b) 1. 2.
3.
4.
5.
c) 1. 2.
3.
4.
5.
d) 1. 2.
3.
4.
5.
e) 1. 2.
3.
4.
5.
3.
3.
3.
3.
3.
3.
3.
3.
3.
4.
4.
4.
4.
4.
4.
4.
4.
4.
5.
5.
5.
5.
5.
5.
5.
5.
5.
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6. Puteai s avei ncredere/ s v confesai prinilor dvs. ?
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_______________
7. V nelegeau prinii dvs. ? ________________________________________
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8. n
fond,
v-ai
simit
iubit
i
respectat
de
prini ?
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______________
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______________
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
C. Mariaj
1. De ct timp v cunoteai soia / soul nainte de a v logodi ?
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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
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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__________
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5.
stimulante
halucinogene( LSD,etc.)
diaree
constipaie
alergii
pusee de tensiune
probleme cardiace
greuri
vom
insomnie
dureri de cap
dureri de spate
treziri timpurii dimineaa
somn sntos( potrivit)
mncat excesiv
apetit srac
mese de proast calitate
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 :
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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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