Couple Assessment Form

(Xm¦Ä \ÂIp¶ hnhc§Ä R§Ä clyambn kq£n¡p¶p. )

Name: Age: Gender:

t]cv hbÊv enwKw

Relationship Status

Married
Separated
Living Together
Divorced
Living apart
Dating

Problem Description ( {][m\{]iv\§Ä)

1. hnImc]camb {]iv\§Ä (Emotional Issues)

2. s]cpamä]camb {]iv\§Ä (Behavioural Issues)

3. Nn´m]camb {]iv\§Ä (Cognitive Issues)

4. imcocnI]camb {]iv\§Ä (physiological Issues)

1
BODY
 Explain your eating habits. What you prefer more? Any issues related to food habits? `£WcoXn
hnhcn¡pI. GXv Xc¯nepÅ `£WamWv IqSpX XncsªSp¡pI.Blmcioehpambn _Ôs¸«v Fs´¦nepw
_p²nap«pIÄ t\cn«ptm

Do you pay attention to the sugar content in the foods/drinks you are consuming? (Xm¦fpsS
`£W¯nse ]©kmcbpsS Afhv \n§Ä {i²n¡mdptm?)

Yes always/Sometimes/Never (Ft¸mgpw, hÃt¸mgpw, {i²n¡mdnÃ)

Do you eat processed foods, candy, cookies or cake containing sugar or any other
sweetener? (inXoIcn¨ Blmc§fmb t_¡dn ]elmc§Ä Ign¡mdptm?)

Yes /No

How many teaspoon of sugar do you use most often to sweeten beverages?
 I do not sweeten (Ign¡mdnÃ)
 I sweeten with 1/2/3/4 or more (Rm³ 1,2,3,4 AXn IqSpX Sokv]q¬ a[pcw
D]tbmKn¡mdpv)
Note :For {men: 9 ts, women: 6 ts, children and teens : less than 25g}

Do you use vegetable oil?

(]mNI¯n\v k¬^vfhÀ Hmbn D]tbmKn¡mdptm?)
Have you tested vitamin D?
(vitamin D sSÌv sNbvXncpt¶m?)
Have you tested vitamin B12?
vitamin B12 (sSÌv sNbvXncpt¶m?)

Do you have vitamin deficiency? If yes describe

(icoc¯n vitamin Ipdhptm?)

 What are your physical activities? How many hours? (ImbnI {]hÀ¯\§fn hymbma¯nÂ
GÀs¸Smdptm ? F{X kabw) Exercise /Play / swimming/Dancing/Cycling/other ( \o´Â /ssk
¢nMv / kv]o¡nwMv /IfnIÄ aäpÅh)

2
  Do you take any medicines? Please explain your medication? (Fs
´¦nepw Xc¯nepÅ acp¶pIÄ Ign¡p¶ptm ,F´n\pÅ acp¶mWv D]tbmKn¡p¶Xv?)

 Have you been in therapy before? If so give details (CXn\v ap³]v sXdm¸nbv¡v
hnt[bambn«ptm Ds¦n hnhc§Ä \ÂIpI )

 Under line any of the following that apply to you or members of your family family(Xmsg
sImSp¯ncn¡p¶hbn Xm¦Ät¡m ho«pImÀt¡m _m[IamIp¶Xv ASnhcbnSpI)

Thyroid, kidney disease, asthma, neurological disease, diabetes, cancer, glaucoma,

epilepsy, ohers (ssXtdmbnUv hr¡tcmK§Ä Bkva , \mUokw_Ôamb {]iv\§Ä,{]talw, AÀ_pZw,
KvCqt¡ma, A]kvamcw , aäpÅh)

 Any head injury or loss of conciousness? If yes describe( Xebv¡v £Xw kw`hn¡pItbm HmÀa\
jvSs¸« kmlNcy§tfm Dmbn«ptm Ds¦n hnhcn¡pI )

 Describe any surgery you had? (ikv{X{Inb¡v hnt[bambn«ptm. Ds¦n hnhcn¡pI )

 Describe any accidents or injuries you have suffered? (A]IS§Ä kw`hn¨n«ptm?)

Menstrual and obsteric history BÀ¯h ,{]khNcn{Xw

Regularity and Duration BÀ¯h¯nsâ {Iahpw Imemh[nbpw:

Length of each cycle BÀ¯hw F{XZnhkw \op\n¡pw:

3
 Abnormality BÀ¯h{Iat¡Sv:

Last menstrual period F¶mWv BÀ¯hw Ahkm\w DmbXv :

No.of children born Ip«nIÄ:

Termination of pregnancy KÀ`On{Zw:

MINDv
 What do you love most about your relationship?v (\n§fpsS _Ô¯nÂ
CjvSs¸Sp¶ Imcy§Ä Fs´ÃmamWv?)

 What was very beginning of your relationship like? How long did this phase
last? (\n§fpsS _Ô¯nvsâ XpS¡w F§s\bmbncp¶p.AXv F{X\mÄ \op\n¶p?)

 What initially attracted you to your partner?(_Ô¯nsâ Gähpw CjvSs¸«ncp¶

Imcy§Ä Fs´ÃmamWv?)

 What are the things you like most about your relationship? What are your
sources of pleasure as a couple?(Z¼XnIÄ F¶\nebn \n§fpsS B\µ¯nsâ
t{imXÊv F´mbncp¶p?)

4
 What are the top 3 things you wish to change in your relationship? When do
you feel most frustrated in your relationship?(\n§fpsS _Ô¯n Gähpw
IqSpX amdphm³ B{Kln¡p¶ Imcy§Ä Fs´ms¡bmWv.Ft¸mgmWv Xm¦Ä
Gähpw IqSpXÂ \ncmi\mbn«pÅXv)

 In what important ways are the two of you similar? Different? What do the
two of you share in common?(\n§fn Hcpt]msebpÅ {][ms¸« Imcy§Ä Fs
´ÃmamWv.Fs´Ãmw Imcy§fmWv s]mXphmbn ]ckv]cw ]¦pshbv¡mdpÅXv)

 Have you had therapy or couple’s counselling in the past? If so when?

Explain what was helpful and what was not?(\n§Ä I¸nÄ Iu¬ken§n\v t\cs¯
hnt[bcmbn«ptm ? Ft¸mgmWv ? \n§Ä¡v klmbIcambn«pÅ Imcy§fpw
AÃm¯ Imcy§fpw hnhcn¡pI)

 What are your greatest fears tied to your relationship?(\n§fpsS

_Ôs¯Ipdn¨pÅ henb `bw)

 What is the hardest part of your relationship for you now?(\n§fpsS _Ô¯nÂ
Ct¸mÄ ITn\ambntXm¶p¶ Imcyw F´mWv)

 Do you think your partner understand you most of the time?(an¡kab§fnepw \

n§fpsS ]¦mfn \n§sf a\Ênem¡mdps¶v tXm¶p¶ptm)

5
  What did you like or love about your partner?(]¦mfnbn Xm¦Ä¡njvSs¸Sp¶
Imcy§Ä)

 What traits do you appreciate in your partner?(]¦mfnbpsS GXv

Imcy§sfbmWv Xm¦Ä A`n\µn¡mdpÅXv)

 What traits do you think your partner appreciates in you?(Xm¦fpsS

GsXÃmw {]hr¯nIsfbmWv ]¦mfn A`n\µn¡mdpÅXv)

 Do you feel supported by your partner? If so how and when?(]¦mfn Xm¦sf

kt¸mÀ«#v sN¿mdps¶v tXm¶nbn«ptm,Ft¸mgmWv tXm¶nbXv)

 Do you feel that you provide your partner with support or encouragement?
How?(Xm¦Ä ]¦mfnbv¡v kt¸mÀ«pw t{]mÕmlhpw \ÂIp¶Xmbn tXm¶p¶ptm ?
F¦n Ft¸mÄ?)

 Use of leisure time (HgnhpthfIÄ F§s\ Nnehgn¡p¶p)

 Tick the feelings that often apply to you (Xm¦Ä¡v AS¡Snbpmhp¶ hnImc§Ä Sn¡v
sN¿pI)

Angry/Annoyed/Guilty/Happy/Unhappy/Bored/Sad/Others tZjyw Ipä¡mc³ kt´mjw

Ak´pjvSw hnckX k¦Sw ieys¸Sp¯pI

6
 What is your self image? (kz´w {]XnÑmb)
Pleasant sexual images/Unpleasant childhood images/Lonely images/Helpless
images/Images of being loved
(kt´mjIcamb ssewKnI {]XnÑmb, Ak´pjvSamb _meyIme {]XnÑmb, GIm´amb
{]XnÑmb, \nÊlmbamb {]XnÑmb,kvt\ln¡s¸Sp¶p F¶ {]XnÑmb)

 Do you have any fears about life?(PohnXs¯Ipdn¨v `baptm)

 How often do you argue?(\n§Ä CSbv¡nsS Ieln¡mdptm)

 What do you most often argue about? (GXv Imcy¯n\mWv hg¡nSmdpÅXv)

 What do you do when you are angry? What does your partner do?(tZjyw hcpt_mÄ
Xm¦Ä F´mWv sN¿p¶Xv. Xm¦fpsS ]¦mfn F´v sN¿pw)

 How long do you stay mad at each other? Who is the first to attempt to make
things better? How do you resolve conflict?(\n§Ä ]ckv]cw F{X t\cw
kwkmcn¡mXncn¡pw {]iv\w ]cnlcn¡m³ BcmWv BZyw ap³ssI FSp¡p¶Xv \n§Ä F§s\
bmWv {]iv\w ]cnlcn¡p¶Xv)

 Describe your most recent argument. How did it start? How did it end?(\n§Ä
ASp¯v Ieln¨Xv hnhcn¡pI. F§s\bmWv XpS§nbXv F§s\ Ahkm\n¨p)

7
  Have there been any incidents of physical violence or threat of violence? If yes
describe (imcocnI ]oU\w `ojWns¸Sp¯pI F¶nh Dmbn«ptm Ds¦n hnhcn¡pI)

 Has there been any infidelity in your relationship?( v\n§fpsS _Ô¯n Ahnizmkw D-
mbn«ptm

Intimacy

 Are you sexually active with your partner? Y /N

(Xm¦Ä ]¦mfnbpambn CSbv¡nsS ssewKoI_Ôw ]peÀ¯mdptm)

 How satisfied are you with your sex life with your partner?
(]¦mfnbpambpÅ ssewKnI_Ô¯n Xm¦Ä F{X Xr]X\mWv)
0 1 2 3 4 5 6 7 8 9 10
Completely unsatisfied completely satisfied
apgph\mbpw AXr]vXn apgph\mbpw Xr]vXn

 Who initiates sex most often?(ssewKnI_Ô¯n GÀs¸Sm³ BcmWv ap³ssI FSp¡p¶Xv)

 Do you commnicate well? (\n§Ä \¶mbn Bibhn\nabw \S¯mdpv)

Y /N

 How open are you in expressing your innermost thoughts and feelings with your partner?
(Xm¦fpsS DÅnepÅ Gähpw kzImcyamb Nn´Ifpw hnImc§fpw ]¦mfnbpambn ]¦pshbv¡mdptm)

0 1 2 3 4 5 6 7 8 9 10

8
Totally closed totally open
]dbmdnà FÃmw Xpd¶v ]dbmdpv

 How connected do you feel to your partner? (\n§fpsS ]¦mfnbpambn \n§Ä¡v F{Xam{Xw
ASp¸apv)
0 1 2 3 4 5 6 7 8 9 10
Completely seperate completely attached

Abuse ]oV\§Ä

 Have you experienced any physical or mental abuse?(imcocnItam am\ÊnItam

Bbn«pÅ ]oV\§Ä Dmbn«ptm)

SOCIAL

How would you describe the home in which you were raised? (Xm¦Ä hfÀ¶ hoSnt\
¸än hnhcn¡pI. A½tbmSpÅ Xm¦fpsS _Ôw hnhcn¡pI)

 Describe your relationship with your mother (A½tbmSpÅ Xm¦fpsS _Ôw hnhcn¡pI)
As a child (Ip«nbmbncp¶t¸mÄ)

Present time Ct¸mÄ)

 Describe your relationship with your father (AÑt\mSpÅ Xm¦fpsS _Ôw hnhcn¡pI)

As a child Ip«nbmbncp¶t¸mÄ:

9
 Present time Ct¸mÄ:

 Describe your parent’s relationship to each other (Xm¦fpsS amXm]nXm¡Ä X½nepÅ

_Ôw hnhcn¡pI)

Growing up hfÀ¨mL«¯nÂ:

Present time Ct¸mÄ:

 Attachment with parents and parents in law (amX]nXm¡tfmSpw A½bnb½,

`mcym,`ÀXr amXm]nXm¡tfmSpw DÅ_Ôw hnhcn¡pI)

 Descriibe your relationship with your children (Xm¦fpsS Ip«nItfmSpÅ _Ôw)

Name Age Rate 1 to10 Quality

 Describe your relationship with your siblings (ktlmZc§tfmSpÅ _Ôw)

Name Age Rate 1 to 10 Quality

10
 Do you or your partner have difficulties with alcohol or substance abuse? If yes describe
(Xm¦Ät¡m ]¦mfnbvt¡m aZyw ab¡pacp¶v XpS§nbh D]tbmKn¡p¶XpsImpÅ BtcmKy{]iv\
§Ä Dtm)

 List some social activities you engage in as a couple (\n§Ä

Hcpan¨v ]s¦Sp¯ ,sN¿p¶ ]cn]mSnIÄ)

Social Activity Freequency Comments

 What social activity do you enjoy the most together?(Hcpan¨v sNbvX F´v
kmaqlnI{]hÀ¯\amWv IqSpX BkzZn¨Xv)

 How comfortable are you doing activities away from your partner? How
comfortable are you with your partner spending time away from you?
(]¦mfnbn \n¶pw amdn \n¶v Imcy§Ä sN¿pt_mÄ AXv F{Xam{Xw \
ÃXmbntXm¶p¶p , Xm¦fpsS ]¦mfn Xm¦fn \n¶v amdn \n¶v {]hr¯n¡pt_mÄ
AXv Xm¦Ä¡v F{Xam{Xw \ÃXmbntXm¶p¶p)

11
  Do you confide in a special person outside of your relationship? If so who?
Describe the relationship (Xm¦fpsS _Ô¯n\v ]pd¯pÅ Hcp hyànsb Xm¦Ä
hnizkn¡p¶ptm BcmWv \n§Ä X½nepÅ _Ôw)

EXISTENTIAL

Identity crisis
(Xm¦fpsS AØnXzw kw_Ôn¨v Fs´¦nepw {]iv\§Ä Dmbn«ptm?

{]XnkÔn L«§fn PohnXt¯mSv aSp¸v tXm¶nbn«ptm

PohnX¯nse Hmtcm \nanjhpw IS¶pt]mIp¶Xv Hcp t]msebmtWm hyXyØamb Fs´¦nepw

\S¡p¶Xmbn A\p`hs¸Smdptm

PohnX¯n hyàamb e£yw Cà F¶v tXm¶nbn«ptm

\n§Ä¡v HcpXhW IqSn P·w FSp¡m³ Ahkcw e`n¨Xn \n§Ä¡v Cu P·¯nse

GsXms¡ sXäpIfmWv Xncp¯m³ {ian¡pI

12
 tPmenbn \n¶v hncan¨m \n§Ä GsXm¡ hgnIfneqsS kwXr]vXn Is¯m³ {ian¡pw

PohnX e£y§Ä t\SnsbSp¡p¶Xn Hcp ]cmPbw Bbn tXm¶nbn«ptm

PohnX¯n H¶pw t\Snbn«nà F¶ tXm¶Â \n§sf Ae«p¶ptm

\ncmim at\m`mh¯n \n¶pw DÅ tamN\w BßlXy Bbn tXm¶nbn«ptm

D¯chmZn¯§Ä \nÀhln¡p¶Xn \n§Ä Hcp ]cmPbamsW¶v tXm¶nbn«ptm

Rm³ BcpsSbpw Bcpw Aà F¶ tXm¶Â DmImdptm

\n§fpsS PohnX¯nsâ \nb{´Ww \n§fpsS I¿n BtWm

 Please outline your most significant memories and experiences within the following
(Gähpw \Ã A\p`h§fpw HmÀaIfpw GXv hbÊnemsW¶v hnhcn¡pI)

0-5 6-10 11-15 15-20 21-25

13
26-30 31-35 36-40 41-45 46-50

51-55 55-60 61-65 66above

 Is there anything else you feel is important to share right now?

({][m\s¸«Xmbn Fs´¦nepw ]dbm³ B{Kln¡p¶ps¦n Ct¸mÄ hnhcn¡pI)

Informed Consent( AdnthmsSbpÅ k½Xw)

I agree that the information provided in this questionnaire is accurate and honest. I understand that
to encourage a healthy and successful couple’s therapy program I need to be honest with my
partner and my Therapist/Counselor. I thus agree to share any pertinent information regarding my
life with my partner named

(Cu tNmZymhenbv¡v Rm³ \ÂInbncn¡p¶ D¯c§Ä IrXyhpw kXykÔhpw BWv..BtcmKyIchpw

hnPbIchpamb Zm¼XyIu¬ken§v \S¯p¶Xn\v Rm³ Fsâ ]¦mfntbmSpw sXdm¸nÌv,
Iu¬knetdmSpw kXykÔambncn¡Ww F¶v a\Ênem¡p¶p. AXn\v ………………………………..F¶ Rm\
pw Fsâ ]¦mfnbmb

…………………………………….sâbpw PohnX¯nse {]kàamb `mK§Ä shfns¸Sp¯m³ k½Xn¡p¶p)

Signature:

Date:

14