Education (last year completed)*
Other training (list type & years completed)*
Referred here by*
Rate Your Health*
Describe your health.*
Your approximate weight (lbs)*
Weight changes recently Gained/Loss*
List all important present or past illnesses, injuries or handicaps*
Date of last medical examination*
Women only: If you experience significant symptoms to your menstrual cycle, please explain
Are you taking any medication*
What (include dosage)?
Have you used drugs for other than medical purposes?*
Do you drink Alcoholic beverages?*
How much and how frequently?
Do you drink coffee*
How much and how frequently?
Other caffeine drinks?*
Do you smoke?*
Have you ever had a severe emotional upset?*
Have you ever had interpersonal problems on the job?
If yes, explain
Have you ever been arrested?*
Have you recently suffered the loss of someone who was close to you?*
Church Attendance per month:*
How are you involved within the church?*
Religious background of spouse (if married)
Do You believe in God?*
Do you pray to God?*
Do you consider yourself to be a Christian?*
How much do you read the Bible?*
Do you have regular family devotions?*
Explain recent changes in your spiritual Life, if any*
Have you ever had any psychotherapy or counseling before?*
If yes, list counselor or therapist and dates
What was the outcome?
Check all the following words which best describe you now:*
Have you ever felt people were watching you?*
Do people's faces ever seem disoriented?*
Do you ever have difficulty distinguishing faces?*
Do colors ever seem?
Are you sometimes unable to judge distance?*
Have you ever had hallucinations?*
Are you afraid of being in a car?*
Is your hearing exceptionally good?*
Do you have problems sleeping?*
Problem Check list*
Change in lifestyle
MARRIAGE AND FAMILY INFORMATION
Name of Spouse
Your spouse's age
Education (in years)
Is spouse willing to come for counseling?
Is he/she in favor of your coming?
if no, explain
Have you ever been separated or filed for divorce?
Date of marriage
Your ages when married.
How long did you know your spouse before marriage?
Give brief information about any previous marriages.
Information about children:
Please include Name, Age, Gender, Living (yes/no), Education *
If you were reared by anyone other than your own parents, briefly explain:
How many older brothers do you have*
How many older sisters do you have?*
How many younger brothers do you have?*
How many younger sisters do you have?*
Describe relationship to your father*
Describe relationship to your mother*
BRIEFLY ANSWER THE FOLLOWING QUESTIONS:
What is your problem? (what brings you here?)*
What have you done about it?*
Are your parents living?*
Do they live locally?
What can we do? (what are your expectations in coming here?)*
As you see yourself, what kind of person are you? Describe yourself.*
What, if anything, do you fear?*
What do you want more than anything else?*
Is there any other information I should know?*