CHESTIONAR PENTRU PACIENI AFLATI SUB

INDRUMARE PSIHOTERAPIE
Nume:
Prenume:
Data naterii:
Locul naterii:
Stimate pacient (),
Nimnui nu-i plac chestionarele. Dar acest chestionar pentru pacieni v folosete, exclusiv,
dumneavoastr i nu este destinat unei cercetari tiinifice.
Este un sprijin n folosul sntii dumneavoastr i tratamentului dumneavoastr individual.
V rog, de aceea, s citii fiecare punct al acestui chestionar i s rspundei cu atenie.
Dac nu tii sau nu suntei sigur(), marcai punctul cu semnul ntrebrii ?.
Luai-v timpul necesar s completai chestionarul n linite, fr a fi presai de obinerea
vreunei perfomane.
Mulumesc pentru colaborare si va multumesc pentru incredere !
I Anamnez
Familie: bolile prinilor sau ale altor membri ai familiei
a)
Mama
Nume

Tata

Varsta
Data decesului
(daca e cazul)
Cauza decesului
b) Frai/ surori ____________________________________________________________
Vrsta:
Sexul:
Data decesului
(daca e cazul):
Boli cunoscute:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Boli ale altor rude de snge (gradul de rudenie): ___________________________________
Boli neurologice sau boli psihice ________________________________________________
Sinucidere__________________________________________________________________
Alte boli
___________________________________________________________________________

Praxis Dr. Grossmann

Medic specialist medicin general, psihoterapie i medicina mediului

c) Suferiti/ ati suferit de alte boli sau operaii?

Daca da, va rog sa completati mai jos care sunt acestea si anul manifestarii fiecareia dintre
ele:
__________________________________________________________________________
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Operaii (de ex. apendicectomie n 1963)
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d) Ati suferit accidente si/sau accidente de munc?
Daca da, precizati cauza, anul accidentului si daca aveti vreun grad de invaliditate
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e) Alte internri in spital, fr operaii
(precizati cauza internarii, anul)
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f) Alte boli: (de ex. hipertensiunea arterial, ficat, rinichi, plmni, inim)
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g) Ati urmat tratamente de reabilitare in ambulator sau intervenii pe termen scurt?
Va rugam sa precizati:
Cauza

Locul

Anul

Cine a facut
decontarea

h) Ati facut investigaii mai deosebite (de ex. CT (computer tomografie), cateterizare
cardiac, endoscopie gastric, EEG (electroencefalogram)?
Investigaie
luna/an
Rezultat (dac e cunoscut)
___________________________________________________________________________
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Cine a propus psihoterapia?
___________________________________________________________________________
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Femei:
La ce varsta ati avut prima menstruatie? __________________________________________
Data ultimei menstruaii: ______________________________________________________
Ciclu menstrual neregulat sau alte acuze? ________________________________________
Nateri ____________________________________________________________________
Avorturi spontane/ avorturi provocate:___________________________________________
Complicaii (dificuli) la natere (de ex. operaie cezarian): _________________________
___________________________________________________________________________
Urmati vreun tratament hormonal? ______________________________________________
Daca da, de care? ____________________________________________________________
Operaii ginecologice? (Pelvis/sn):______________________________________________
Ultimul control periodic: ______________________________________________________
Rezultat_________________________
Brbai:
Data ultimului control periodic: _________________________________________________
Rezultat: ___________________________________________________________________

1.Date generale:
Aveti pofta de mancare? _______________________________________________________
Ati avut cretere sau scderi n greutate n ultimile 6 luni? ____________________________
Daca da, cate kg? ____________________________________________________________
Cate lichide pe zi beti? _______________________________________________________
Aveti vreo durere la urinare? ___________________________________________________
Mergi des la toaleta pe parcursul nopii? __________________________________________
De cate ori si cauza: ____________________________________________________
Aveti tulburri de somn? _____________________________________________________
Cte ore dormiti noaptea?___________________________________________________ore
Aveti dificulti de adormire sau de a rmne adormit? ______________________________
Daca da, mentionati cauzele: ___________________________________________________
Tuse____________ Expectoraie________Alergii_________________________________
Cum v alimentai? (v rog marcai cu o cruciuli)
echilibrat
deficitar (de ex. neechilibrat fast food )
bogat n grsimi
vegetarian
Ct alcool consumai pe zi/sptmn/lun?________________________________________
Cte igri fumai pe zi?_______________________________________________________
De cnd nu mai fumai?________________________________________________________
Activiti sportive:
___________________________________________________________________________
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Urmtoarele mi se potrivesc: (v rog marcai cu o cruciuli)
hipertesiune arterial cunoscut din ____
lipide sanguine mrite, cunoscute din ____
deficit de exerciiu fizic
perioade de repaus deficitare
consum regulat de analgetice/somnifere (precizati va rog tipul acestora)
___________________________________________________________________
Cum m descurc cu stresul cotidian:
constituire rar o problem pentru mine
deja, la mici suprasolicitri reacioneaz prin creterea tensiunii interioare
cea mai mic suprasolicitare m dezechilibreaz
n situaii de stres mi pierd des stpnirea de sine
chiar n situaii care ar necesita-o, am probleme si devin agresiv ()
sau ______________________________________________________________________

2. Suferinte/ probleme actuale:

Ce acuze avei n acest moment? (att corporale, ct i sufleteti)
___________________________________________________________________________
De cnd au aprut aceste acuze?
___________________________________________________________________________
Ct de des apar acuzele?
___________________________________________________________________________
Exist situaii n care acuzele se nrutesc sau cnd se amelioreaz ?
___________________________________________________________________________
(De ex. dureri de cap de 5 ani de aproximativ 1-2 ori pe sptmn mai puternice, de un an
n situaii de stres profesional)
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Aceste acuze v limiteaz activitatea profesionale/ viaa de familie/ timpul liber?
Dac da, descriei pe scurt aceste limitri.
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n momentul debutului acuzelor, ai avut evenimente stresante n via?
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Cum v explicai aceste acuze, care credei c este cauza lor?
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Ai luat deja msuri s v modificai/mbuntii starea de sntate sau s v ameliorai

acuzele?
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3. Terapie actual
Ce fel de medicamente luai? (Doze/De cnd)
Medicament
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Dimineaa
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Prnz
_______
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Seara
____________
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____________
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Din
_________________
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_________________
_________________
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Ce fel de medicamente ai luat mai demult, ca s diminuai acuzele? (doz/ n ce perioad?)

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Suntei la momentul actual n tratament psihoterapic? (v rog marcai cu o cruciuli)
Da
Nu
De cnd?__________ Ct de des?______________ Durata edinelor____________minute
(de ex. din 1998, 1 dat pe sptmn, 50 minue)
Ati facut psihoterapie? Precizati tipul, anul, frecventa
(de ex. terapie comportamental din 1995, 25 de ore, aproximativ o dat pe sptmn, 50 de
minute)
___________________________________________________________________________
___________________________________________________________________________
4. Biografia mea
Sunt nscut() n: ____________________________________________________________
Am crescut n:_______________________________________________________________
___________________________________________________________________________
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Frai/surori: (v rog precizai sexul, i diferena de vrst fa de dumneavoastr, de ex. sor,

-3 ani etc.)
1.____________________ ______ ani
2.____________________ ______ ani
3.____________________ ______ ani
4.____________________ ______ ani
5.____________________ ______ ani
6.____________________ ______ ani
7.____________________ ______ ani
8.____________________ ______ ani

Mama mea a avut la naterea mea vrsta de ___________ ani, de profesie

___________________________________________________________________________
Tatl meu a avut la naterea mea vrsta de ___________ ani, de profesie
___________________________________________________________________________
Rezultate ale nvestigaiilor mamei de pe perioada sarcinii (n msura n care se cunosc):
___________________________________________________________________________
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Marcati cu x, simptomele care vi se potrivesc si care au avut loc n copilrie:
Sperieturi nocturne
(Pavor nocturn)
Roaderea unghiilor
Copilrie nefericit

Udarea patului
(Enurezis)
Blbial
Comaruri

Somnambulism

Sugerea degetului

Team

Copilrie fericit

Alte probleme din copieria ?

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5. Situaie generala de via
necasatorit(a)
cstorit()
vduv()
divorat(a)
desprit(a)

Partener de via/ De cnd?___________________

din ____________
pn la _________________
din ____________
pn la _________________
din ____________
din ____________
din_____________

Cati copii aveti? ___________________________________________

Care e vrsta lor?___________________________________________
Partenerul/partenera de via lucreaz? ___________________________________________
Care e profesia lui/ei? ________________________________________________________
Cum este platit? cu ora cu norm ntreag,
Lucreaza in ture inverse? ______________________________________________________
Este pensionar()? ___________________________________________________________
Locuina: (cas, apartament nchiriat, cte camere)_________________________________
___________________________________________________________________________
Cte persoane aveti in intretinere? _______________________________________________
Condiii de locuit sunt bune/ suficiente/ nesatisfctoare/ deranjante prin?________________
___________________________________________________________________________
___________________________________________________________________________
Precizati care sunt activitile dn timpul liber i eventualele hobby-uri
:__________________________________________________________________________
___________________________________________________________________________
Cand ati avut ultimul concediu (cnd i unde)? ____________________________________
Suprasolicitri personale la momentul actual (de ex. financiare, datorii, ngrijire, parteneriat,
construcia casei, etc.)? _______________________________________________________
___________________________________________________________________________
___________________________________________________________________________
6. Profesie
V rog s v prezentai ruta profesional, ncepnd cu terminarea colii (separat pe ani:
terminarea colii/nvtur/perfecionare/ocupaiile)
Dezvoltare profesional
________________________________________________
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Anii (de la..................pn la)

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Ocupaia actual:_______________________________ din: __________________________

Ocupaia actual (subliniai v rog ceea ce se potrivete)
stau jos, n picioare, n aer liber, n spaiu nchis, acas, cltoresc

V rog s descriei concret munca:

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Durata de munc (subliniai v rog ce se potrivete)
norm ntreag,
jumtate de norm,
n schimburi,
la banda,
munci ocazionale,
munc la domiciliu
Completri:____________________________________________________________
Sptmnal__________ore Ore suplimentare?________
Loc de munc (subliniai v rog ce se potrivete)
Luminos,
lumin artificial
ntunecos
zgomot
praf,
contact intens cu publicul
Completri: _________________________________________________________________
Drumul ctre serviciu: cte ore pe zi dus-ntors la serviciu?___________________________
Gradul de mulumire la locul de munc (subliniai v rog ce se potrivete):
Bun
satisfctoare
sczut,
absent?
Completri: _________________________________________________________________
Preconizai s v schimbai meseria? ____________________________________________
___________________________________________________________________________
V-ati recalificat? _____________________________________________________________
Sunteti somer la momentul actual?_________ de cnd?_____________________________
La momentul actual n concediu de boal?___________ de cnd?_____________________
Din ce cauz?________________________________________________________________
Cte sptmni/luni ai fost n concediu medical n ultimele 12 luni?____________________
Ati cerut pensie?
Nu Da
de cnd? _________________
Vi s-a acordat pensia?
Nu Da
de cnd? _________________
Vi s-a refuzat cererea de pensie
Nu Da de cnd? _________________
Au fost obiectii la cererea de pensionare? Nu Da de cnd? _________________
Handicap sever? (gradul)_______ procente. Din ce cauz?____________________________
Boli profesionale recunoscute:__________________________________________________
Suntei n legtur cu medicul de ntreprindere (de ex. imbold ctre psihoterapie)?
___________________________________________________________________________

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Numii 5 temeri (frici) principale
1._________________________________________________________________________
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2._________________________________________________________________________
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3._________________________________________________________________________
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4._________________________________________________________________________
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5._________________________________________________________________________
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7. Informaii despre sexualitate

a. Atitudinea prinilor fa de sexualitate
(de ex. Dac acas la dumneavoastr vi s-a fcut educaie sexual sau ai avut discuii despre
sexualitate?)
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b. La ce vrst ai aflat primele lucruri despre sexualitate?
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c. Cnd ai fost pentru prima dat contient/contient de pornirile sexuale?
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d. Ai avut vreodat sentimente de vinovie legate de sexualitate sau de masturbare. Dac da,
v rog s descriei aceste sentimente in amanunt:
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V rog s ne informai despre detaliile eseniale ale primei experiene sexuale sau despre cele
care au urmat
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Viaa sexual actual o considerai satisfctoare? (Dac nu,v rog completai)
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V rog s ne informai despre preferintele dumneavoastr heterosexuale (i/sau
homosexuale):
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8. Prinii
V rog s descriei trsturile de caracter ale tatlui i atitudinea sa fa de dumneavoastr
(mai demult i la momentul actual):
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V rog s descriei trsturile de caracter ale mamei i atitudinea sa fa de dumneavoastr
(mai demult i la momentul actual):
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Cnd ai fost copil, cum ai fost pedepsit() de prini?

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ncercai s prezentai (descriei) atmosfera casei parentale (cminul n care ai crescut.
Amintii cum s-au neles prinii ntre ei i cu copiii):
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Ai putut avea ncredere n prinii dumneavoastr?
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Dac ai avut un tat sau o mam vitreg, ce vrst ai avut cnd printele dumneavoastr s-a
recstorit? (Cum ai descrie relaia cu cu mama sau tatl vitreg?):
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Conturai, pe scurt, educaia dumneavoastr religioas?
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Dac nu ai fost crescut de prinii dumneavoastr, cine v-a crescut i la ce vrst ?

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9. Altele
S-a amestecat cineva (prini, rude, prieteni) vreodat n csnicia, profesia dumneavoatr?
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Care sunt oamnenii cei mai importani din viaa dumneavoastr?
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Sufer vreun membru al familiei dumneavoastr de alcoolism, epilepsie sau de ceva are
poate fi considerat boal psihic? (Descriei mai amnunit aceste suferine):
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Prezentai v rog toate experienele care v-au produs team sau suferin i pe care nu le-ai
amintit nc:
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10. Autodescriere
V rog completai urmtoarele:
Eu sunt ____________________________________________________________________
Eu m simt _________________________________________________________________
Eu cred ____________________________________________________________________
mi doresc__________________________________________________________________
V rog s v descriei n cuvinte cheie aa cum v-ai descrie singur:
De ctre dumneavoastr:
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De ctre soul/soia (partener/partenera de via):
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De ctre cel mai bun prieten/ cea mai bun prieten:
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De ctre cineva care nu v place pe dumneavostr:
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11.Scopurile terapiei
V modelai terapia mai eficient, dac reflectai la scopurile terapiei sau modificrile pe care
dorii s le facei n ariile urmtoare, pn la sfritul psihoterapiei:

Din punct de vedere sufletesc, vreau s ating (temeri, inhibiii, depresii, etc.):
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Corporal vreau s ating:
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Social vreau sa ating (familie, parteneriat, relaia cu ceilali, etc.):
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Profesional vreau s ating (capacitate de lucru, scopuri profesionale, probleme profesionale):
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Referitor la mine nsumi vreau s ating:
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12. Scurt tabel autobiografic cu suprasolocitrile/experienele emoionale cele mai importante
(desprire, moarte, experiene ale pierderii, castorie, nateri, etc.)
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13. Observaii propii relevante
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II Anamneza familial
1. Condiii de locuit n copilrie............................
....................................................................
Arie geografic: _____________________________________________________________
Ora: ______________________________________________________________________
Ati stat la casa sau la bloc? _____________________________________________________
Cte persoane ati fost n familie? _______________________________________________
Ati avut camer proprie? ______________________________________________________
Ati avut vreun sentiment de strmtorare ? _ _______________________________________
Cand si unde v-ati mutat cu locuinta? ____________________________________________
2. Mama
Ocupatie : Casnic Activ n cmpul muncii
Din ce mediu provine mama?
________________________________________________
Relaia cu mama:
a) in timpul copilriei timpurii a fost:
sever
distanta
a stat mult acasa;

Observaii
Ce mai doriti sa exprimati din probleme, viata, copileria, relatia, familia dv. sau simtiti
nevoie sau doriti sa scrieti.
Folositi o forma llibera si cuvintele dv. cu cat sunteti mai autentic in exprimarea cu atit
munca noastra va fi mai usoara:
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