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Questionnaires

LIFE HISTORY QUESTIONNAIRE

The purpose of this questionnaire is to obtain a comprehensive picture of
your background. By completing these questions as fully and as accurately
as you can, you will facilitate your therapeutic program. You are requested
to answer these questions in your own time instead of using up time during
your session.
It is understandable that you might be concerned about what happens to
the information about you because much or all of this information is highly
personal. Case records are strictly confidential. NO OUTSIDER IS
PERMITTED TO SEE YOUR CASE RECORD WITHOUT YOUR
PERMISSION.



















    D) Check any of the following that applied during your childhood:
    Night terrorsBed wettingSleepwalkingThumb-suckingNail bitingStutteringFearsHappy childhoodUnhappy childhood










    L) Check any of the following that apply to you:
    HeadachesFinancial problemsFainting spellsPalpitationsDizzinessNo appetiteBowel disturbancesStomach troubleInsomniaNightmaresFatigueAlcoholismFeel tenseTake sedativesTremorsDepressedFeel panickyTake drugsUnable to relaxSuicidal ideasShy with peopleSexual problemsCan’t make decisionsDisorientedCan’t make friendsOverambitiousCan’t keep a jobDon’t like weekends and vacationsUnable to have a good timeConcentration difficulties








    T) Do you make friends easily?
    YesNo

    U) Do you keep them?
    YesNo

    Living or deceased?
    LivingDeceased

    Living or deceased?
    LivingDeceased





    Are you regular:
    YesNo


    Do you experience pain?
    YesNo

    Do your periods affect your moods?
    YesNo


    Have you ever been pregnant?
    YesNo



    Abortion:
    YesNo

    Miscarriage :
    YesNo