COLEGIO DE STA. LOURDES OF LEYTE FOUNDATION, INC.

TABONTABON, LEYTE
Brgy. 1 Quezon, Tabontabon, Leyte

Name: RHEYLANE KIM M. BENZON Course/Yr.&Sec: BSN 1-E GROUP 2

Instructor: HASSEN ZABALA ENRIQUEZ Subject: NCM 101 Date: 6/13/2022

PSYCHOLOGICAL ASSESSMENT FORM

NAME: AGE: DATE OF BIRTH:

ADDRESS: SEX:

 Growth and Development

o What would you say about your physical wellbeing?

o How do you solve a problem in your life?

o How is your emotional stability?

o Do you have trouble using your body for a variety of activities?

o Do you have a habit of being too inactive or unproductive?

o Do you struggle in any form of control such as your thoughts and behaviors?

o Do you struggle to organize and prioritize your tasks?

o Do you have trouble recalling pieces of information from your life?

o Do you struggle to comprehend your own language or speech? Including in your mother tongue?

o Do you have trouble communicating?

 Stress Adaptation
o Have you been feeling stress lately?

o How do you deal your stress? What are things you do?

o What is the most challenging experience you have had? How did you handle it?

o Do you have an experience where you have difficulty in making a decision? How did you respond to
it?

o How do you cope up with the changes in your life?

 MENTAL STATUS
o How are you feeling right now?

o What have you been thinking about lately? Do you have a habit of thinking about things?

o Have you ever considered committing suicide? If so, how?

o Do you feel sad for a long about a certain situation? What do you do when it happens?

o What advice could you give to someone who is mentally unstable?

 SOCIAL STATUS
o What is your relationship status?

o How many are you in your house?

o How would you describe your current situation?

o Do you have difficulty socializing with others?

o How would you describe your set of friends?

 SOCIAL SUPPORT
o What do you do when you are in need of someone?

o Who do you go to when you have a problem? Why?

o How does your family help during crisis?

o What does your set of friends do when you have a problem in a certain thing?

o Whom do you ask for advice, why?

 FAMILY AND RELATIONSHIP

o What is your marital status?

o How is your relationship with your family and other people?

o How often do you join social gatherings?

o How do you get along with other people? Are you the first one to approach?

o Who matters more to you, your family or your friends?