Mealer Psychological, PLLC
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                                                                                            Life History Questionaire

                                                                                                                        Date:_____________

I.              General Information

Name:________________________________________________________________________

Address:_______________________________________________________________________

Phone: (Home):_______________________ (Work):__________________________________

Cell:_____________________________

Age:_____  Occupations:_________________________Gender:___________

Referred by:___________________________________________________________________

May I acknowledge the referral?  Yes   No

Marital Status:  Single   Engaged     Married    Separated     Divorced     Widowed

Remarried (how many times? _____)  Living with someone

Do you live in a:  house     hotel     room     apartment _______________________

2.            Description of Presenting Problem

State in your own words the nature of your main problems:

 

 

On the scale below, please estimate the severity of your problem(s) now.

Mildly upsetting   Moderately upsetting        Very Severe                          Extremely Severe

When did your problems begin?  Dates

 

Please describe significant events occurring at that time, or since then, which may relate to the development or maintenance of your problems.

 

What solutions to your problems have been most helpful?

 

Have you been in therapy before or received any prior professional assistance for your problems?  If so, please give names, professional titles, dates of treatment, and results.

 

3.            Personal and Social History

Date of Birth:__________     Place of Birth:___________________________________________

Siblings:_______________________________________________________________________

Father:  Age_____ (or age at death _____ and your age  _____ cause of death_____________)

Mother: Age____ (or age at death_____ and your age _____ cause of death ______________)

Religion: As a child_________________________________ As Adult______________________

Education: Last grade completed (degree) ___________________________________________

Scholastic Strengths and weaknesses:

Underline any of the following that applied during your childhood/adolescence:

Happy childhood  School Problems  Medical Problems                Unhappy childhood

Family Problems  Alcohol abuse                       Emotional problems           Behavior problems

Strong religious convictions                                               Legal Trouble                        Drug abuse

Other:

What sort of work are you doing now? _____________________________________________

What kinds of jobs have you held in the past? _______________________________________

Does your present work satisfy you? If not please explain:

Annual Family income:__________  How much does it cost you to live?___________________

What were your past ambitions? __________________________________________________

What are your current ambitions?_________________________________________________

What is your height?_______  Weight”________

Have you lost or gained significant weight in the past 6 mos?  Y  N  pounds _____

on purpose?  Y  N

Have you ever been hospitalized for a psychological problem?   Y   N  If yes, when and where?

Do you have a family physician? Y  N  Name and phone:________________________________

Have you ever attempted suicide?  Y  N

Does any member of your family suffer from a mental disorder?_________________________ ______________________________________________________________________________

Has any relative or friend committed suicide? ________________________________________

Has any relative had serious legal problems?_________________________________________

4. Behavior

Circle any of the following that apply to you:

Overeat Suicide attempts Can’t keep job                      Take drugs             Compulsions

Insomnia               Vomiting               Smoke                    Take risks               odd behavior                        Lazy

Withdrawal           Lazy        Drink too much    Nervous Tic           Eating Problems      Work too much

Trouble concentrating        aggressive behavior                            procrastination    Crying

Sleep Disturbance               Impulsive Reactions                            Phobic Avoidance                Temper

Loss of Control

Are there any specific behaviors, actions, or habits you would like to change?

 

What are some special talents or skills that you feel proud of?

 

What would you like to do more of? _______________________________________________

What would you like to do less of? _________________________________________________

What would you like to start doing?________________________________________________

What would you like to stop doing?________________________________________________

How is your free time spent?______________________________________________________

Do you keep yourself compulsively busy doing an endless list of chores or meaningless activities?  _____________________________________________________________________

Do you practice relaxation or meditation regularly?___________________________________

 

 

 

5.            Feelings

Circle any of the following feelings that often apply to you.

Angry                     Guilty                     Unhappy                Annoyed                Happy                     Bored                    

Depressed             Regretful               Lonely                    Anxious  Hopeless                Contented

Fearful                   Hopeful  Excited                   Panicky   Helpless Optimistic

Energetic               Relaxed  Tense                     Envy                        Jealous

List your 5 main fears:

1.

2.

3.

4.

5.

What feelings would you like to experience more often?

What feelings would you like to experience less often?

What are some positive feelings you have experienced recently?

When are you most likely to lose control of your feelings?

Describe any situations that make you feel calm or relaxed?

Please complete the following:

If I told you what I’m feeling now __________________________________________________

One of the things I feel proud of is_________________________________________________

One of the things I feel guilty about is ______________________________________________

I am happiest when_____________________________________________________________

One of the things that saddens me the most is_______________________________________

If I weren’t afraid to be myself I might _____________________________________________

I get so angry when_____________________________________________________________

If I get angry with you ___________________________________________________________

What kinds of hobbies or leisure activities do you enjoy or find relaxing?

Do you have trouble relaxing and enjoying weekends and vacations? Please explain if yes.

6.            Thoughts

Circle any of the following that often apply to you.                                

I am worthless, a nobody, useless or unloveable

I am unattractive, incompetent, stupid or undesirable

I am evil, crazy, degenerate or deviant

Life is empty, a waste, there is nothing to look forward to

I make too many mistakes, can’t do anything right

I picture myself:

Being hurt     Not coping     hurting others     succeeding     failing     losing control

Being trapped     being followed     being laughed at    being talked about

Being promiscuous     others

What picture comes into your mind most often?

Describe a very pleasant image, mental picture, or fantasy.

 

Describe your image of a completely safe place.

 

How often do you have nightmares?

Do you have recurrent dreams? 

Circle the words you might use to describe yourself:

Intelligent, confident, worthwhile, ambitious, sensitive, loyal, trustworthy, full of regrets, worthless, a nobody, useless, evil, crazy, morally degenerate, considerate, a deviant, unattractive, unlovable, inadequate, confused, ugly, stupid, naïve, honest, incompetent, horrible thoughts, conflicted, concentration difficulties, memory problems, attractive, can’t make decisions, suicidal ideas, persevering, good sense of humor, hard-working

What do you consider to be your most irrational thought or idea?

Are you bothered by thoughts  that occur over and over again?

 

 

Please complete the following:

I am a person who______________________________________________________________

All my life_____________________________________________________________________

Ever since I was a child___________________________________________________________

It’s hard for me to admit_________________________________________________________

One of the things I can’t forgive is__________________________________________________

A good thing about having problems is______________________________________________

The bad thing about growing up is_________________________________________________

One of the ways I could help myself but don’t is______________________________________

On each of the following items, please circle (Strongly agree, agree, neutral, disagree, strongly disagree)

                                                                                                                                SA           A             N             D             SD

I should not make mistakes

I should be good at everything I do

When I do not know I should pretend to

I should not disclose personal information

I am a victim of circumstance

My life is controlled by outside forces

Other people are happier than I am

It is very important to please other people

Play it safe; don’t take any risks

I don’t deserve to be happy

If I ignore my problems they will disappear

It is my responsibility to make others happy

I should strive for perfection

There are 2 ways to do things, the right way

And the wrong way

 

7.        Expectations regarding Therapy:

In a few words, what do you think therapy is all about?

 

How long do you think your therapy should last?

How do you think a therapist should interact with his or her clients? What personal characteristics do you think the ideal therapist should possess?

 

8.        Interpersonal Relationships

If you were not brought up by your parents, who raise you and between what yrs?

Give a description of your father’s (or father substitute’s) personality and his attitude toward you (past and present).

Give a description of your mother’s (or mother substitute’s) personality and his attitude toward you (past and present).

In what ways were you disciplined (punished) by your parents as a child?

Give an impression of your home atmosphere growing up. Mention state of compatibility between parents and between children.

Were you able to confide in your parents?

Did your parents understand you?

Basically, did you feel loved and respected by your parents?

If you have a step-parent, what age were you when your parents remarried?

Has anyone ever interfered in your marriage, occupation, etc?

Who are the most important people in your life?

 

Do you make friends easily?

Do you keep them?

Were you ever bullied or severely teased?

Describe any relationships that give you

     Joy

     Grief

How relaxed and comfortable are you in  social situations?  Very relaxed, relatively comfortable, relatively uncomfortable, very anxious

Generally do you express your feelings, wishes, and opinions to others in an open, appropriate manner? Describe those individuals with whom (or situations) you have trouble asserting yourself.

Did you date much during High School?  College?

Do you have one or more friends with whom you feel comfortable sharing your most private thoughts and feelings?

Marriage:

How long did you know your spouse before your engagement?

How long have you been married?

What is your spouse’s age?

What is your spouse’s occupation?

Describe your spouse’s personality

In what areas are you compatible?

In what areas are you incompatible?

How do you get along with your inlaws?

How many children do you have?  Please give names and ages and gender.

Do any of your children present special problems?

Any relevant information regarding abortions or miscarriages?

Sexual Relationships:

Describe your parent’s attitude toward sex. Was sex discussed in your home?

When and how did you derive your first knowledge of sex?

When did you first become aware of your own sexual impulses?

Have you ever experienced any anxiety or guilt feelings arising out of sex or masturbation? If yes, please explain.

Any relevant details regarding your first or subsequent sexual experiences?

Is your present sex life satisfactory? If not, please explain.

Provide information about any significant homosexual reactions or relationships.

Please note any sexual concerns not discussed above.

Other Relationships:

Are there any problems in your relationships with people at work?  If yes, please describe.

 

Please complete the following:

One of the ways people hurt me is_________________________________________________

I could shock you by_____________________________________________________________

A mother should________________________________________________________________

A father should_________________________________________________________________

A true friend should_____________________________________________________________

Give a brief description of yourself as you would be described by:

Your spouse (if married):

Your best friend:

Someone who dislikes you:

Are you currently troubled by any past rejections or loss of a love relationship? If yes, please explain.

10.       Biological Factors

Do you have any current concerns about your physical health?

 

Please list any medication you are currently taking or have taken in the past 6 mos.

 

Do you eat 3 well-balanced meals each day?

Do you get regular physical exercise?  Type and frequency?

 

Underline any of the following that apply to you or members of your family:  thyroid disease, kidney disease, asthma, neurological disease, infectious disease, diabetes, cancer, gastrointestinal disease, prostate problems, glaucoma, epilepsy, other:

Have you had a head injury or loss of consciousness? Please give details.

 

Surgeries, accidents, or injuries?

                                                                                                                             Never        Rarely     Frequently           Often

Marijuana

Tranquilizers

Sedatives

Aspirin

Cocaine

Painkillers

Alcohol

Coffee

Cigarettes

Narcotics

Stimulants

Hallucinogens

Diarrhea

Constipation

Allergies

High Blood Pressure

Heart Problems

Nausea

Vomiting

Insomnia

Headaches

Backache

Fitful Sleep

Overeat

Poor Appetite

Eat “junk” foods

Sequential History:

Please outline your most significant memories and experiences within the following ages:

0 – 5 _________________________________________________________________________________________

6 – 10_________________________________________________________________________________________

11 -15________________________________________________________________________________________

16-20_________________________________________________________________________________________

21-25_________________________________________________________________________________________

26-30_________________________________________________________________________________________

31-35_________________________________________________________________________________________

36-40_________________________________________________________________________________________

41-45_________________________________________________________________________________________

46-50_________________________________________________________________________________________

51-55_________________________________________________________________________________________

56-60_________________________________________________________________________________________

61-65_________________________________________________________________________________________

Over 65_______________________________________________________________________________________

 

 

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