FIS A DE CUNOAS TERE

Chestionar multimodal al istoriei viet ii (adaptat dup Chestionar-ARNOLD

LAZARUS)

Completand acest chestionar cat mai sincer s i detaliat, vet i facilita procesul de
cunoas tere. Suntet i rugat i sa completat i raspunsurile la aceste i ntrebari de rutina i n loc
sa folosit i timpul real de consultat ie. Este de i nt eles daca va preocupa ce se i ntampla
cu informat iile despre dvs.,pentru ca multe sau aproape toate aceste informat ii sunt i n
cel mai i nalt grad personale. Aceste fis e sunt strict confident iale. Nici o alta
persoana nu are acces la aceste fis e fa ra permisiunrea dvs. Daca nu dorit i sa
raspundet i la unele i ntrebari, va rugam sa scriet i : ,,nu doresc sa raspund.

I.Informat ii generale
Nume:_________________________________________________
Adres:________________________________________________
Numere de telefon, email:_________________________________
_______________________________________________________
Varsta: ____
Ocupat ia: ____________________
Sex: _____
Cum ai ajuns n cadrul terapeutic:___________________________________
____________________________________

Statutul marital (i ncercuit i) : Singur/; Logodit/; Casatorit/; ntr-o relaie; ntr-o

relaie fr obligaii; Separat/; Divort at/; Vaduv/; Recasatorit/ (de cate
ori)_________ Traiesc (locuiesc) i mpreuna cu cineva
Locuiesc i n: casa, hotel, camera, apartament

II. Descrierea ateptrilor de la procesul de consiliere:

Descriet i cu cuvintele dumneavoastra ce ateptri avei de la procesul de consiliere:
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At i mai primit asistent a psihologic? Daca da, va rugam specificai tipul intervent iei,
durata s i rezultatele :
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III. Istorie personala s i sociala
Data nasterii ________________ Locul nasterii ___________________________
Frat ii: numarul frat ilor ________Varsta frat ilor ___________________________
Numarul surorilor _______Varsta surorilor_________________________
Tatal: i n viat a ________ Vrsta actual _______________
Ocupat ia __________________ starea de sanatate___________________________
Decedat ________la ce varsta _____data decesului___________________________
Ce varsta aveat i atunci?______________________
Cauza mort ii__________________________________________________________
Mama: i n viat a ________ Vrsta actual _______________
Ocupat ia __________________ starea de sanatate __________________________
Decedat ________la ce varsta _____ data decesului__________________________
Ce varsa aveat i atunci?______________________
Cauza mort ii __________________________________________________________
Religia: i n copilarie _____________________ la maturitate
_________________________
Educat ia: (care este ultimul nivel absolvit) ____________________________
Puncte forte s i puncte slabe i n s coala :
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Subliniat i ceea ce se potriveste copilariei / adolescent ei dvs. :
Copilarie fericita
Copilarie nefericita
Probleme legale
Probleme educat ionale
Probleme comportamentale
Abuz de alcool
Probleme medicale
Probleme s colare
Probleme familiale
Convingeri religioase puternice
Abuz de drog
Altele (specificai) _______________________________
Ce fel de munca desfasurat i acum?(ocupat ia)_____________________________
Ce fel de slujbe at i avut i n trecut?
______________________________________________
Munca actuala va satisface ? (daca nu, va rugam sa explicat i)

Care au fost abilitat ile dvs. i n trecut?

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Care sunt abilitat ile dvs. actuale?
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At i fost spitalizat pentru probleme psihiatrice? (Dac da, dai detalii)

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At i avut tentative suicidare? (dac da dai detalii context, consecint e)
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Sufera cineva din familia dvs. de (ncercuii): alcoolism; depresie; epilepsie; orice
altceva care poate fi considerat ,, tulburare mentala ?
A avut / comis vreo ruda tentativa de suicid?
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IV.Analiza pe modalita tI a tabloului psihic general

Sect iunea urmatoare este conceputa pentru a va ajuta sa va descriet i tabloul curent i n
detaliu.
1. Comportament
Subliniat i fiecare din comportamentele urmatoare care va caracterizeaza :
Supraalimentat ie
Consum de droguri
Voma
Comportament ciudat
Consum prea mare de bautura
Munca prea multa / grea
Amanare
React ii impulsive
Pierderea controlului
Asumare a prea multor riscuri
Tentative suicidare
Compromisuri
Fumat
Izbucniri de furie ( ies it din sarite)
Retragere
Ticuri nervoase
Dificultat i de concentrare
Tulburari de somn
Evitare fobica
Incapacitate de a desfas ura un anumit tip de munca( mutari frecvente )
Insomnie
Lene
Probleme de alimentat ie
Comportament agresiv
Plans
Exista comportamente, act iuni sau obiceiuri pe care at i dori sa le schimbat i?
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Care sunt talentele/ aptitudinile/ abilitat ile cu care va mandrit i ?
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Ce at i vrea sa facet i maimult?
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Ce at i vrea sa facet i mai put in?
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Ce at i vrea sa i ncepet i sa facet i ?

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Ce at i vrea sa i ncetat i sa mai facet i ?
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Cum va petrecet i timpul liber ?
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In compania cui ?(detalii anturaj)
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Va ment inet i ocupat i n mod compulsiv facand un s ir nesfars it de activitat i
nesemnificative ?
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2. Sentimente
Subliniat i fiecare din sentimentele urmatoare care vi se potrivesc ( pe care le resimt it i)
adesea :
Furios; plictisit; suparat; deprimat; anxios; temator; panicat; energic; invidios;
vinovat; fericit; conflictual; plin de regrete; lipsit de sperant a; plin de sperant a;
relaxat; gelos; nefericit; trist; fara odihn; singur; mult umit; stimulat; optimist;
tensionat; altele (descriei) _________________________________________

Listat i principalele frici/ temeri ale dvs. :

1._______________________________________________________
2._______________________________________________________
3._______________________________________________________
4._______________________________________________________
5._______________________________________________________

Care sunt sentimentele pe care le i ncercat i cel mai des ?

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Ce sentimente / emot ii at i vrea sa trait i mai put in des ?
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Enumerat i cateva din sentimentele/ emot iile pozitive pe care le-at i trait de curand
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Cand suntet i cel mai adesea pe cale sa va pierdet i controlul asupra sentimentelor /
emot iilor dvs. ?
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Descriet i o situat ie semnificativa pentru acest lucru
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Descriet i situat iile care va fac sa va simt it i calm, relaxat
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Va rugam sa completat i :
Daca v-as spune sincer ce simt acum ar fi
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Unul din lucrurile de care ma simt mandru este
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Unul din lucrurile de care ma simt vinovat este
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Sunt cel mai fericit cand
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Unul din lucrurile care ma supara cel mai tare este
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Daca nu mi-ar fi teama sa fiu eu i nsumi, as putea sa
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Daca ma supar pe tine
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Ce fel de lucruri recreative sau hobby-uri va fac placere, va relaxeaza ?

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Avet i dificultat i sa va relaxat i / odihnit i / distrat i i n weekend-uri s i vacant e ? Daca da,
va rugam sa explicat i
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3. Senzatii fizice
Subliniat i senzat iile pe care le resimt it i adesea :
Dureri de cap; Amet eal; Palpitat ii; Spasme musculare; Tensiune; Tulburari (dureri)
sexuale; Incapacitate de relaxare (agitaie motorie); Tulburari intestinale; Furnicaturi
Tiuituri i n urechi; Deranj stomacal; Ticuri; Oboseala; Contract ii musculare; Dureri de
spate; Tremuraturi; Momente de les in/slabiciune, Zgomote auzite; Ochi apos i;
Probleme de auz; Probleme de piele; Gura uscata; Mancarimi sau arsuri de piele;
Dureri de piept; Batai rapide de inim; Neplacerea de a fi atins; Transpirat ie excesiva
Tulburari de vedere; Amort eala; Altele (specificai)
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4. Imagini
Subliniat i fiecare din elementele care va caracterizeaza :
Imagini de a fi iubit; Imagini sexuale placute; Imagini de neajutorare; Imagini
agresive; Imagini sexuale neplacute; Imagini de singuratate, Imagini de seduct ie

Verificat i care din urmatoarele vi se potrivesc : Ma vad pe mine i nsumi ( ma

imaginez) ca:
Fiind lovit
Neputand sa fac fat a
Avand succes
Pierzandu-mi controlul
Fiind urmarit
Fiind barfit
Lovind pe alt ii
Fiind responsabil
Es uand
Fiind prins i n cursa
Fiind ridiculizat
Facand promisiuni
Altele _____________________________________

Ce imagine va vine i n minte cel mai des ?

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Descriet i o imagine, un tablou mental sau o fantezie foarte placuta
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Descriet i o imagine, un tablou mental sau o fantezie foarte neplacuta
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Descriet i imaginea dvs.despre un loc complet sigur
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5. Ga nduri
Subliniat i fiecare din urmatoarele ganduri care vi se potrivesc:
-Sunt lipsit de valoare, un nimeni, inutil s i/ sau nedemn de a fi iubit
-Sunt neatragator, incompetent, stupid s i/ sau indezirabil
- Sunt rau, nebun, degenerat s i/ sau deviant
- Viat a este goala, un pustiu, nu este nimic spre care sa caut i sa te i ndrept i ( i n viitor)
- Fac prea multe gres eli, nu fac nimic corect, bine
- Nimic descris mai sus nu m reprezint

Subliniat i fiecare din urmatoarele cuvinte pe care le-at i putea utiliza pentru a va
descrie:
Inteligent; Increzator; Meritoriu (valoros); Ambit ios; Sensibil; Loial; De i ncredere;
Plin de regrete; Lipsit de valoare; Un nimeni; Inutil; Rau; Nebun; Degenerat moral;
Atent; Un deviant neatragator; Nedemn de a fi iubit; Inadecvat; Confuz; Urat; Prost;
Stupid; Naiv; Onest; Incompetent; Cu ganduri oribile; Conflictual; Cu dificultat i de
concentrare; Cu probleme de memorie; Atragator; Nu pot lua decizii; Cu idei
suicidare; Perseverent i ncapat anat; Bun simt al umorului; Muncitor

Care considerat i ca este cel mai irat ional gand (idei pe care le avet i)?
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Suntet i deranjat de ganduri care revin mereu ?
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Pentru fiecare din itemii urmatori, va rugam s notai numarul care reflecta cel mai
fidel opiniile dvs. :
1-dezacord 2-dezacord puternic 3- neutru 4-acord 5-acord puternic
a) Ar trebui sa nu fac gres eli
b) Trebuie sa fiu bun i n tot ce fac
c) Cand nu s tiu, ar trebui sa pretind ca s tiu
d) Ar trebui sa nu dezvalui informat ii personale
e) Sunt o victima a circumstant elor
f) Viat a mea este controlata de fort e exterioare
g) Alt i oameni sunt mai fericit i decat mine
h) Este foarte important sa-i mult umes ti pe ceilalt i
i) Joaca singur; nu-t i asuma nici un fel de riscuri
j) Nu merit sa fiu fericit
k) Daca i mi ignor problemele, ele vor disparea
l) Este responsabilitatea mea sa-i fac pe ceilalt i oameni fericit i
m) Trebuie sa tind/ sa ma straduiesc spre perfect iune
n) La baza sunt doua moduri de a face lucrurile : modul bun corect s i modul
prost, gres it

Va rugam sa completat i urmatoarele propoziii cu ce v vine n minte:

Sunt o persoana care
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Toata viat a mea

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Inca de cand eram copil
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Este greu pentru mine sa admit c
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Unul din lucrurile pe care nu le pot ierta este
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Cand i t i faci probleme
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Lucrul rau cand cres ti mare este
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Unul din modurile i n care as putea sa ma ajut , dar nu o fac este
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6. Relatiile interpersonale
A. Familia de origine
1. Daca nu at i fost crescut de parint i, cine v-a crescut s i i ntre ce ani ?
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2. Dat i o descriere a personalitat ii tatalui ( sau a substitutului tatalui) s i a atitudinii lui
( prezente s i trecute) fat a de dvs.
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3. Dat i o descriere a personalitat ii mamei ( sau a substitutei mamei ) s i a atitudinii ei
(prezente s i trecute) fat a de dvs.
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4. In ce moduri at i fost disciplinat ( pedepsit) de parint i cand erat i copil ?
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5. Relatat i o impresie asupra atmosferei casei dvs. ( casa i n care at i crescut).
Ment ionat i starea de compatibilitate dintre parint i s i dintre parint i s i copii.
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6. Puteat i sa avet i i ncredere/ sa va confesat i parint ilor dvs. ?
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7. Va i nt elegeau parint ii dvs. ?
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8. V-at i simt it iubit s i respectat de parint i ?
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9. Daca avet i un parinte vitreg, precizat i varsta la care parintele s-a recasatorit
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10. S-a amestecat vreodata cineva ( parint i, rude, prieteni) i n mariajul sau munca dvs.,
etc. ?
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11. Care sunt cei mai apropiat i oameni din viat a dvs. ?
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B. Prietenii
Va facet i prietenii cu us urint a________________________________________
Ii pastrat i ?_______________________________________________________
At i fost vreodata terorizat sau ironizat dur ?____________________________
Descriet i o relat ie care va ofera:
Bucurie
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Suparare
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Notat i masura i n care va simt it i i n general confortabil s i relaxat i n situat iile sociale
(i ncercuit i):
Foarte relaxat; relativ confortabil; relativ inconfortabil; foarte anxios

In general, va exprimat i sentimentele, opiniile sau dorint ele i ntr-un mod deschis s i
adecvat ?_______________________________________________________
Descriet i indivizii fat a de care ( sau i ntrebarile i n care ) avet i dificultat i sa fit i asertivi.
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Avet i unul sau mai mult i prieteni cu care sa va simt it i confortabil, sa va i mpartas it i
cele mai intime ganduri sau sentimente ?
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C. Mariaj
De cat timp va cunos teat i sot ia / sot ul i nainte de a va logodi ?
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Cat timp at i fost casatorit ? _________________________________________
De cat timp suntet i casatorit ? _______________________________________
Care este varsta sot iei/ sot ului dvs. ? __________________________________
Care este ocupat ia sot iei/ sot ului dvs. ?________________________________
Descriet i personalitatea sot iei / sot ului dvs. _____________________________
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In ce arii suntet i compatibili ? ______________________________________
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In ce arii suntet i incompatibili ? ______________________________________
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Cum va i nt eleget i cu rudele dvs. prin aliant a ( socrii, cumnat i,etc.)?
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Cat i copii avet i ? ____________
Nume ________________________________ _____________________________
Varsta ________________________________
Prezinta vreunul dintre ei probleme speciale ? ___________________________
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D. Relatii sexuale
Descriet i atitudinea parint ilor dvs. fat a de sex. Se discuta despre sex acasa?
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Cand s i unde at i obt inut primele informat ii despre sex?
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Cand at i devenit prima data cons tient de propriile impulsuri sexuale ?
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At i trait vreodata sentimente de anxietate sau vinovat ie provocate de sex sau
masturbare ? Daca da, va rugam sa explicat i
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Detalii relevante privind primele experient e sexuale

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Viat a dvs. sexuala prezenta este satisfacatoare? Daca nu, va rugam explicat i
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Oferit i informat ii despre orice react ie sau relat ie homosexuala pe care o avei (sau ai
avut-o)
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Va rugam notat i orice problema / preocupare sexuala nediscutata mai sus
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E. Alte relatii
Sunt probleme i n relat iile cu oamenii la serviciu ? Daca da, va rugam descriet i
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Va rugam completat i urmatoarele :
a) unul din modurile i n care oamenii ma ranesc este
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b) as putea sa ochez prin ________________________________________________
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c) o mama ar trebui s
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d) un tata ar trebui s
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e) un prieten adevarat ar trebui s
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Dat i o scurta descriere a dvs. as a cum at i fi descris de :

-sot ia/ sot ul dvs.
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-cel mai bun prieten
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-cineva care va agreaza
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-cineva care nu va agreaza

Suntet i i n mod obis nuit afectat de faptul de a fi respins i n trecut sau de pierderea de
prietenie/ colegialitate ?Daca da, va rugam explicat i
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Suntet i i n mod obis nuit afectat de faptul de a fi respins i n trecut sau de pierderea unei
relat ii de dragoste ?Daca da, va rugam explicat i
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F. Factorii biologici
Avet i preocupari curente legate de sanatatea dvs. fizica? Va rugam explicat i
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Va rugam enumerat i medicamentele pe care le luat i i n mod curent sau pe care le-at i
luat i n ultimele 6 luni ( inclusiv aspirina, pilule anticoncept ionale sau medicamente
prescrise sau autoadministrate)
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Avet i i n fiecare zi trei mese echilibrate ? Daca nu, va rugam explicat i
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Facet i i n mod regulat exercit ii fizice ? Daca da, ce tip s i cat de des ?
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Verificat i ( i ncercuit i ) care din urmatoarele va caracterizeaza ( vi se potrivesc) :

Marijuana; Tranchilizante; Sedative; Aspirin; Cocain; Analgezice; Alcool; Cafea;
Tigari; Stimulante halucinogene( LSD,etc.); Diaree; Constipat ie; Alergii; Pusee de
tensiune; Probleme cardiace; Gret uri; Voma; Insomnie, Dureri de cap; Dureri de
spate; Treziri timpurii dimineat a; Somn sanatos( potrivit); Mancat excesiv; Apetit
sarac; Mese de proasta calitate; Altele (specificai)
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Subliniat i oricare din urmatoarele care se aplica membrilor familiei dvs. : boli
tiroidiene, boli de rinichi , astm, boli neurologice, boli infect ioase, diabet, cancer, boli
gastrointestinale, probleme de proststa, glaucom, epilepsie, altele (specificai)
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At i avut vreodata boli ale corpului sau pierderi de cons tiint a ? Va rugam dat i detalii
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Va rugam descriet i orice operat ie chirurgicala pe care at i avut-o ( dat i date- vrst,
cum v-a afectat)
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Descriet i orice fel de accidente sau traumatisme de care at i suferit ( dat i date)

Istoria etapelor
Va rugam scriet i cele mai semnificative amintiri sau experient e de l a urmatoarele
varste :

0 la 5 ani
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6-11
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11-15
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16-20
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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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