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_______________________________________________________________________________________
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_______________________________________________________________________________________
