STRESS ASSSESMENT AND PSYCHOSOCIAL SURVEY QUESTIONNAIRE

KLUB PSYCHOLOGY

Please fill the form and mail us!

Socio-demographic information

gfd÷Name:.......................................................            gful/s÷Nationality:.................................

pd]/–ln·/Age–Sex:..............................................         Period of stay in Nepal:.............................

a}aflxs l:ylt÷Marital status:...............................           i) Since:.....................................................

lzIff÷Education:..................................................        ii) For/ Purpose:........................................

k]zf÷bIftf÷Occupation/Proficiency:.......................................................................................

7]ufgf÷Address: i) :yfoL÷Permanent:......................................................................................

ii) c:yfoL÷Temporary:............................................................................................

Od]n÷Email ID:....................................kmf]g÷Phone No.:..................... ldlt÷Date:................

Stress Asssesment and Psychosocial Survey Questionnaire:

A.  Stress Asssesment / tgfj ljZn]if0f

!= lat]sf !% lbgdf jf s]lx ;do cl3 b]lv 36]sf k|d'v # 36gfx? pNn]v ug'{xf];\ h;n] tkfO{sf] lbgx'Fsf] hLGbuLnfO{ Psbd} tgfjdo agfP .

      List 3 major life events that occurred within 15 days and have created an unbearable stress on your day to day living.

      i)_________________________________________________________________________________________

      ii)________________________________________________________________________________________

      iii)________________________________________________________________________________________

@=   lat]sf ^ dlxgfdf 36]sf k|d'v # 36gfx? pNn]v ug'{;\ h;n] tkfO{nfO{ Psbd} lrGtLt agfP .

      List 3 major life events which have elevated your anxiety since 6 months.

      i)_________________________________________________________________________________________

      ii)________________________________________________________________________________________

      iii)________________________________________________________________________________________

#=   s] tkfO{;Fu oL tgfj / lrGtfx?;Fu h'‰gsf nfuL s]xL cfkm\gf / To:tf t/Lsf / pkfox? 5g\ < 5g\ eg] pNn]v ug'{xf];\ .

      Do you have your own coping mechanisms and solutions towards these stressful situations and anxieties? If any, list some of them.

      i)_________________________________________________________________________________________

      ii)________________________________________________________________________________________

B.   PSYCHOSOCIAL SURVEY / dgf];fdflhs ;j]{If0f

!=   s] tkfO{nfO{ dfgl;s of zf/Ll/s :jf:Yo ;DaGwL cGt/lqmofdf efu lng] rfxgf 5 <                                                       5÷5}g

     o; cl3 klxn] o:tf sfo{qmddf efu lng' ePsf] lyof] <                                                                                    5÷5}g

     s] s:tf] ljifodf cGt/lqmof ug]{ jf hfgsf/L kfpg] tkfO{df OR5f 5 <                                                                     

      Do you want to participate in interactions about mental or medical health ?                                                           Yes/No  

       Have you ever participated in such talks before ?                                                                                                          Yes/No

      Let us know the topic you would like to interact about.                                                                                       

      __________________________________________________________________________________________

@=   dfgl;s :jf:Yo af/]df tkfO{sf] 5/l5d]s÷kl/jf/÷;fyLefO{x?nfO{ s] slt hfgsf/L 5 <                                                   

     o; cl3 slxNo} s] tkfO{n] cfkm\gf] ufpF, zx/ jf If]qsf] dgf];fdflhs l:ylt yfxf kfpg] k|of; ug'{ePsf] 5 < s;/L < slxn] <                   

      Can you share how much do you, your family, friends & neighbour know about the mental health ?

      Have you ever tried to know the psychosocial scenario of your village, town, region, etc. before? How? When?

     __________________________________________________________________________________________

#= cfkm\gf] 5/l5d]sdf dfgl;s ;d:of ePsf JolQmx? / dgf];fdflhs ?kdf lj5§sf] JolQmTjsf] af/]df tkfO{sf] s] wf/0ff 5 <                                            What is your attitude towards psychosocially abnormal & different people seen around your neighbourhood ?   

     __________________________________________________________________________________________

$=  o:tf ;d:of ePsf sf]xL 5g\ eg] M  If you know any one of them please tell us their:

      Name / gfd M_____________________________________Age / pd]/ M ___________            Sex / lnª M ________________            Adress / 7]ufgf M_______________________________________________________            Phone / kmf]g M______________    

C.  YOUR SUGGESTION / tkfO{sf ;'emfjx? M

     tkfO{nfO{ xfd|f] kl/rofTds cGt{lqmof sfo{qmd s:tf] nfUof] <===========================================================================================================================

     o;nfO{ cem k|efjsf/L agfpgsf] nflu s]xL /fo ;'emfj n]lvlbg'xf];\ .===============================================================================================================

      How do you rate our orientation and interaction progrmme?______________________________________________

      Can you helps us to make it more effective? __________________________________________________________

;"rgf s]Gb|: Klub Psychology

   ;]tf] 3f]8f

;efu[xrf]s, kf]v/f

                                                                                                             Seto Ghoda, Sabhagriha Chowk, Pokhara, Nepalemail:klubpsychology@gmail.com

http://www.klubpsychology.blogspot.com

Our motto: One step ahead everyday.