Date:

GENERAL

Complete name

Age

Address

City
State
Zip Code

Phone Number: (H)
(B)
Cell

Email

Employed By

Person To Contact In Case of Emergency:
Full Name
Phone Number
Address

CLINICAL

A) State the nature of your main problems and their duration:

B) Give a brief account of the history and development of your complaints
(from onset to present):

C) On the scale below please estimate the severity of your problem (s):
Mildly upsetting

Moderately severe

Very severe

Extremely severe

Totally incapacitating

D) Whom have you previously consulted about your problem (s):

PERSONAL DATA

A) Date of birth

B) place of birth

C) Mother’s condition during pregnancy (as far as you know)

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

E) Health during childhood? (List illnesses)

F) Health during adolescence: (List illnesses)

G) What is your:
Height?
Weight?

H) Any surgical operations? (Please list them and at what age):

I) Any accidents? (Please list them and at what age):

J) When were you last examined by a doctor?

K) List your five main fears:

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
M) History of drug use? (Please list age when started):

N) Are you presently using drugs? (If so, please list them):

O) Do you drink alcoholic beverages? (If so, please list what kind and how often):

P) Present interests, hobbies and activities:

Q) How is most of your free time occupied?

R) What is the last grade of schooling that you completed?

S) Scholastic abilities; strengths and weaknesses:

T) Do you make friends easily? YesNo
U) Do you keep them? YesNo

FAMILY DATA

A) Father:

If deceased, your age at the time of his death?
Cause of death

If alive, father’s present age?
Occupation
Health

B) Mother:

If deceased, your age at the time of his death?
Cause of death

If alive, mother’s present age?
Occupation
Health

C) Siblings:

Number of brothers and ages :
Number of sisters and ages :

Relationship with siblings:

A) Past:
B) Present:
Was there any sexual and/or mental abuse?
(If so, please explain):

Were you able to confide in your parents?
Is there a history of mental illness in your family?
Was the problem treated by a psychiatrist?

Does any member of your family suffer from
alcoholism or drug abuse?
(If so, please give details):
Recount any fearful or distressing
experiences not previously mentioned:

Have you ever lost control
(e.g., temper or crying or aggression?)
(If so, please describe)::
List the benefits you hope to derive from therapy:

MENSTRUAL HISTORY

Age at first period?

Are you regular: YesNo
Duration

Do you experience pain? YesNo
Do your periods affect your moods? YesNo
Date of last period?

Any history of gynecological problems?

Have you ever been pregnant? YesNo

If yes, How many times?

Abortion: YesNo
Miscarriage : YesNo
Any relevant details regarding miscarriage (s) or abortion (s)?

SECOND QUESTIONNAIRE

If the answer to any of the following questions is YES, please
describe the event (s) in detail.

1. Have you ever seen a UFO?

2. Have any members of your immediate family seen a UFO?

3. As a child, did you ever experience any odd periods of time of an hour or more when you
were lost but you don’t remember being lost?

4. As an adult have you had any periods of lost or missing time of an hour or more that strike you as being unusual?

5. Do you have any scars on your body that neither you nor your parents can remember how you
received?

6. While awake have you actually seen a frightening figure as a child/and or adult in your
bedroom, closet or anywhere else?

7. Have you ever dreamed about UFOs?

8. Have you ever actually left your body, or had an explicable or unwanted out-of-body
experience?

9. Have you ever seen inexplicable lights or balls of light in your room or house?

10. Have you ever woken up paralyzed with a sense of a person, presence or something else in
the room?