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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
suprtoare

moderat
suprtoare

foarte severe

extrem de severe

total invalidante

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? _____________________________________


_________________________________________________________________________
_
_________________________________________________________________________
_
_________________________________________________________________________
_
Ai mai primit asisten psihologic pentru problemele dvs. ? Dac da, v rugm
specificai numele specialistului, tipul interveniei, durata i rezultatele :
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
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
Copilrie nefericit
Probleme legale
Probleme educaionale
Probleme comportamentale
Abuz de alcool

probleme medicale
probleme colare
probleme familiale
convingeri religioase puternice
abuz de drog
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
Consum de droguri
Vom
Comportament ciudat
Consum prea mare de butur
Munc prea mult / grea
Amnare
Reacii impulsive
Pierderea controlului
Asumare a prea multor riscuri
Tentative suicidare
Compromisuri
Fumat
Izbucniri de furie ( ieit din srite)

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

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


________________________________________________________________________
Care sunt talentele/ aptitudinile/ abilitile cu care v mndrii ? _____________________
________________________________________________________________________
________________________________________________________________________
Ce ai vrea s facei mai mult?________________________________________________
Ce ai vrea s facei mai puin ?_______________________________________________
Ce ai vrea s ncepei s facei ?______________________________________________
________________________________________________________________________
Ce ai vrea s ncetai s mai facei ? ___________________________________________
_________________________________________________________________________
Cum v petrecei timpul liber ?________________________________________________
_________________________________________________________________________
_________________________________________________________________________
n compania cui ?(detalii anturaj) _____________________________________________
_________________________________________________________________________
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
plictisit
suprat
deprimat
anxios
temtor
panicat

energic
invidios
vinovat
fericit
conflictual
plin de regrete
lipsit de speran

plin de speran
relaxat
gelos
nefericit
trist
fr odihn
singur

mulumit
stimulat
optimist
tensionat
altele

Listai principalele frici/ temeri ale dvs. :


1._______________________________________________________
2._______________________________________________________
3._______________________________________________________
4._______________________________________________________
5._______________________________________________________
Care sunt sentimentele pe care le ncercai cel mai des ?____________________________
_________________________________________________________________________
Ce sentimente / emoii ai vrea s trii mai puin des ?_____________________________
_________________________________________________________________________
Enumerai cteva din sentimentele/ emoiile pozitive pe care le-ai trit de curnd ?_______
_________________________________________________________________________
_________________________________________________________________________
Cnd suntei cel mai adesea pe cale s v pierdei controlul asupra sentimentelor /
emoiilor dvs. ?____________________________________________________________
Descriei o situaie semnificativ pentru acest lucru _______________________________
_________________________________________________________________________
_________________________________________________________________________
Descriei situaiile care v fac s v simii calm, relaxat ___________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
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 ? _______________
________________________________________________________________________
________________________________________________________________________

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


rugm s explicai_________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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 sexuale neplcute


imagini de singurtate
imagini de seducie

imagini de a fi iubit

Verificai care din urmtoarele vi se potrivesc :


M vd pe mine nsumi ( m imaginez) ca:
Fiind lovit
Neputnd s fac fa
Avnd succes
Pierzndu-mi controlul
Fiind urmrit

fiind brfit
lovind pe alii
fiind responsabil
eund
fiind prins n curs

fiind ridiculizat
fcnd promisiuni
altele________________
_____________________

Ce imagine v vine n minte cel mai des ? _______________________________________


_________________________________________________________________________
_________________________________________________________________________
Descriei o imagine, un tablou mental sau o fantezie foarte plcut ___________________
________________________________________________________________________
________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Descriei o imagine, un tablou mental sau o fantezie foarte neplcut _________________
________________________________________________________________________
________________________________________________________________________

_________________________________________________________________________
_________________________________________________________________________
Descriei imaginea dvs.despre un loc complet sigur ________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
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
ncreztor
Meritoriu (valoros)
Ambiios
Sensibil
Loial
De ncredere
Plin de regrete
Lipsit de valoare
Un nimeni
Inutil
Ru
Nebun

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)? ________________
________________________________________________________________________
________________________________________________________________________
Suntei deranjat de gnduri care revin mereu ? ___________________________________
________________________________________________________________________
Pentru fiecare din itemii urmtori, v rugm ncercuii numrul care reflect cel mai fidel
opiniile dvs. :
1.dezacord
puternic

2.dezacord

3. neutru

a) Ar trebui s nu fac greeli


b) Trebuie s fiu bun n tot ce fac
c) Cnd nu tiu, ar trebui s pretind c tiu

4. acord

5. acord
puternic

a) 1. 2.
b) 1. 2.
c) 1. 2.

3.
3.
3.

4.
4.
4.

5.
5.
5.

d) Ar trebui s nu dezvlui informaii personale


d) 1. 2.
e) Sunt o victim a circumstanelor
e) 1. 2.
f) Viaa mea este controlat de fore exterioare
f) 1. 2.
g) Ali oameni sunt mai fericii dect mine
g) 1. 2.
h) Este foarte important s-i mulumeti pe ceilali
h) 1. 2.
i) Joac singur; nu-i asuma nici un fel de riscuri
i) 1. 2.
j) Nu merit s fiu fericit
j) 1. 2.
k) Dac mi ignor problemele, ele vor disprea
k) 1. 2.
l) Este responsabilitatea mea s-i fac pe ceilali oameni fericii l) 1. 2.
m) Trebuie s tind/ s m strduiesc spre perfeciune
m) 1. 2.
n) La baz sunt dou moduri de a face lucrurile : modul bun
n) 1. 2.
corect i modul prost, greit

3.
3.
3.
3.
3.
3.
3.
3.
3.
3.
3.

4.
4.
4.
4.
4.
4.
4.
4.
4.
4.
4.

5.
5.
5.
5.
5.
5.
5.
5.
5.
5.
5.

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 ______________________
_________________________________________________________________________
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. __________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
3.
Dai o descriere a personalitii mamei ( sau a substitutei mamei ) i a atitudinii
ei ( prezente i trecute) fa de dvs. __________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
4.
n ce moduri ai fost disciplinat ( pedepsit) de prini cnd erai copil ?
_______________________________________________________________________________
_______________________________________________________________________________
5.
Relatai o impresie asupra atmosferei casei dvs. ( casa n care ai crescut).
Menionai starea de compatibilitate dintre prini i dintre prini i copii. ___________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
6.
Puteai s avei ncredere/ s v confesai prinilor dvs. ?
_______________________________________________________________________________
7.

V nelegeau prinii dvs. ? ________________________________________

______________________________________________________________________________
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
______________________________________________________________________________
______________________________________________________________________________
10.
S-a amestecat vreodat cineva ( prini, rude, prieteni) n mariajul sau munca
dvs., etc. ? _____________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
11.
Care sunt cei mai apropiai oameni din viaa dvs. ? ______________________
_______________________________________________________________________________
_______________________________________________________________________________
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
__________________________________________________________________
__________________________________________________________________
___________________________________________________________________
Suprare
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
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. ____________________________________________________________
__________________________________________________________________
__________________________________________________________________

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

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. _____________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
7.
n ce arii suntei compatibili ? ______________________________________
___________________________________________________________________
___________________________________________________________________
8.
n ce arii suntei incompatibili ? ______________________________________
___________________________________________________________________
___________________________________________________________________
9.
Cum v nelegei cu rudele dvs. prin alian ( socrii, cumnai,etc.) ?
________________________________________________________________
___________________________________________________________________
10.
Ci copii avei ? ____________Nume ________________________________
_____________________________Vrsta ________________________________
11.
Prezint vreunul dintre ei probleme speciale ? ___________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
D. Relaii sexuale
1.
Descriei atitudinea prinilor dvs. fa de sex. Se discuta despre sex acas?
__________________________________________________________________
__________________________________________________________________
2.
Cnd i unde ai obinut primele informaii despre sex?
__________________________________________________________________
__________________________________________________________________
3.
Cnd ai devenit prima dat contient de propriile impulsuri sexuale ?
__________________________________________________________________
__________________________________________________________________
4.
Ai trit vreodat sentimente de anxietate sau vinovie provocate de sex sau
masturbare ? Dac da, v rugm s explicai_____________________________
___________________________________________________________________
5.
Detalii relevante privind prime experien sexual sau cele ulterioare
________________________________________________________________

6.

7.

8.

___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Viaa dvs. sexual prezent este satisfctoare? Dac nu, v rugm explicai
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Oferii informaii despre orice reacie sau relaie homosexual
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
V rugm notai orice problem / preocupare sexual nediscutat mai sus
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

E. Alte relaii
1.
Sunt probleme n relaiile cu oamenii la serviciu ? Dac da, v rugm descriei
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
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_____________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
F. Factorii biologici
Avei preocupri curente legate de sntatea dvs. fizic ? V rugm explicai
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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)
________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Avei n fiecare zi trei mese echilibrate ? ________________________________________
Dac nu, v rugm explicai __________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Facei n mod regulat exerciii fizice ? Dac da, ce tip i ct de des ?
_________________________________________________________________________
Verificai ( ncercuii ) care din urmtoarele v caracterizeaz ( vi se potrivesc) :
Marijuana
Tranchilizante
Sedative
Aspirin
Cocain
Analgezice
Alcool
Cafea
igri

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 ____________________
_________________________________________________________________________
_________________________________________________________________________
Ai avut vreodat boli ale corpului sau pierderi de contiin ? V rugm dai detalii
_________________________________________________________________________
_________________________________________________________________________
V rugm descriei orice operaie chirurgical pe care ai avut-o( dai date)
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Descriei orice fel de accidente sau traumatisme de care ai suferit ( dai date)

_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Istoria etapelor
V rugm subliniai ( scriei) cele mai semnificative amintiri sau experiene de a
urmtoarele vrste :
0-5______________________________________________________________________
6-11_____________________________________________________________________
_________________________________________________________________________
11-15 ____________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
16-20 ____________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
21-25 ___________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
26-30 ____________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
31-35 ____________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
36-40 ____________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
41-45 ____________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
46-50 ____________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
51-55 ___________________________________________________________________

_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
56-60 ____________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
61-65 ____________________________________________________________________