Leslie M. Drozd, Ph.D.
Clinical Psychology, PSY 10317
Marriage and Family Therapy, MFC 19633
1001 Dove St., Ste. 110
Newport Beach, CA 92660
Voice mail: 949.786.7263
fax: 949.851 .1456
e-mail: lesliedrozd@gmail.com
Name: __________________________________________________Age: ________Date: ___________________________________
I completed this form at the request of______________________________________________________________________
Psychological/Social History (PSH)
Directions: Please use a black felt-tip or ballpoint pen if possible. Answer these questions as they apply to
you. Circle the right answers, or fill them in as needed. In some cases, circle as many responses as you feel
apply to you. If you think of an answer that better applies to you than the choices we have provided, feel free to
write it in. You don't need to feel limited by the choices we've given you. If none of the multiple choice
responses to a question apply to you, circle the Not Applicable or None of the above category, so we will know
you reviewed all the items. In some questions where a different answer is possible, we've left you a space
marked
Other: write in your answer here if none of the other answers apply to you or if you wish to provide additional
information.
Warning for those completing this questionnaire In conjunction with a legal matter: We assume that clients
completing the questionnaire for treatment purposes are doing their best to disclose completely in their own
best interests. However, in legal cases, we can't make the same assumption. The temptation to present one's
self as "better" or "worse" than one really is arises in legal cases, so we have found it necessary to post a
warning. Occasionally we've had a client who lied to us on an examination, which was subsequently discovered,
and then we were forced to revoke what would have otherwise been a favorable recommendation for that
individual. Hence, our goal in writing this warning is not to unduly frighten anyone but to remind you of the
serious consequences and potential embarrassment to yourself if errors or omissions occur. You'll be given a
chance to add or change any information at the time of interview, but you should do your best to be the most
complete and accurate while you are completing the questionnaire.
Do not lie on this questionnaire: rather than lie, if there is a part of an item you do not want to answer, write Decline to answer" in the margin on the left side of the specific part of the item you are leaving out. In other
words, you might be willing to answer all parts of a question except one or two, and beside that particular part
you should write -decline to answer" in the margin. A declined answer is not damaging whereas a lie can be.
Too many declined answers may mean that we do not have data needed to make a determination of the issues
in your case, but we can discuss during the interview whether this is true in your particular case. You have
rights of privacy, which you should exercise when you feel the need to do so, and we will explain how this
mayor may not impact your particular case. It is most often the case that an honest answer with negative
information will be less of a problem than withholding or altering information. You are free to consult with
your attorney before answering if you wish.
Complete this questionnaire carefully and completely--don't rush through. If you have any questions
about the instructions, stop right now and ask us. Or, if you need clarification at any time, please feel free to ask.
Use the last page or add additional pages if needed for more room. If you took this questionnaire for a legal
case, you are requested to sign the statement of understanding on Page 38.
1
1a. What is your racial background or origin?
1.
2.
3.
4.
5.
6.
7.
_____Asian/Oriental
_____Black
_____Caucasian (white)
_____Hispanic/Latin
_____Mexican American
_____American Indian
_____Other racial background:______________________
1 b.
Where were you born? U.S_____ Foreign country ____If foreign born, at what age did you come
to the U.S.? ________
1c.
What is your first language? ________________________________
What is your second language? _______________________________
What language was spoken most of the time at home during your
growing up years? ___________________________________________
1d.
Do you identify with a particular cultural/religious background and heritage?
No ___Yes ____If yes, please describe briefly:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
2.
Who raised you, and at what ages?
[For example, if you were raised by maternal grandparents from ages 7-10, write that in on
line 10 or 11.]
Ages: Raised by:
1.________________Natural parents
2. ________________Father only
3.________________Mother only
4.________________Father and stepmother
5.________________Mother and stepfather
6.________________Adoptive parents
7.________________Foster parents
8.________________Aunt or uncle
9.________________Brother or sister
10.______________Maternal grandparent(s) [Mother's parents]
11.______________Paternal grandparent(s) [Father's parents
12. _____________Institutional caretakers, such as juvenile hall, ranch, group home, or treatment facility
13. _____________Employed caretakers in the home, e.g. nannies
14.______________Other:___________________________________________________________________________________________
2
3.
How would you describe your childhood?
1.
Boring, dull
10.
Neglected
2.
Contented
11.
Painful
3.
Conflicted
12.
Perfect
4.
Frightening
13.
Regimented
5.
Happy
14.
Secure
6.
Hard to remember
15.
Unhappy
7.
Insecure
16.
Other: _____________________________________________
8.
Interesting
9.
Lonely
What stands out in your memory about your early childhood prior to starting school?
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
What stands out about your middle childhood [elementary school years, ages 6·12]?
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
What stands out about your junior high and high school years [13-18]?
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
4.
How would you describe your mother [or mother substitute]? If you are not describing
your natural mother, please indicate whom you are describing:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Abusive
Accepting
Affectionate
Controlling
Distant
Demanding
Domineering
Fault-finding/critical
Involved
Loving
11.
12.
13.
14.
16.
16.
17.
18.
Over-protective
Perfect
Strict
Rejecting
Understanding
Uncaring/disinterested
Other: _____________________________________________
Not applicable (no mother or mother substitute)
Additional comments about your mother or mother substitute:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
In what ways are you (1) the most like and (2) the most different from your mother? [Use your
own words. Not words from the list above)
(1)_________________________________________________________________________________________________________
(2)_________________________________________________________________________________________________________
3
5.
How would you describe your father [or father substitute]? If you are not describing
your natural father, please indicate whom you are describing: _____________________________
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Abusive
Accepting
Affectionate
Controlling
Distant
Demanding
Domineering
Fault-finding/critical
Involved
Loving
11.
12.
13.
14.
16.
16.
17.
18.
Over-protective
Perfect
Strict
Rejecting
Understanding
Uncaring/disinterested
Other: _____________________________________________
Not applicable (no father or father substitute)
Additional comments about your father or father substitute:
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
In what ways are you (1) the most like and (2) the most different from your father? [Use your own
words, not words from the list above.]
(1 ) ________________________________________________________________________________________________________________
(2) ________________________________________________________________________________________________________________
Any other comments about parents or parent substitutes and your relationship with them?
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
6.
How would you describe your parents' (or parent substitutes') relationship with each
other?
1.
Close
8.
Reserved
2.
Cold
9.
Distant/indifferent
3.
Ideal
10.
Happy
4.
Violent/abusive
11.
Domineering/submissive
5.
Full of conflict
12.
Loving
6.
Hot and cold
13.
Hostile
7.
Game playing
14.
Other: _____________________________________________
15.
Not applicable (no relationship)
7.
How many times was your mother married? _________Times
How many times was your father married? __________Times
4
8.
In your family, how many brothers and sisters did you have? Fill information about
them. If no brothers and sisters, half brothers or sisters, or stepsiblings, write in Not
Applicable. Include siblings that have died, indicating age at time of death. And, please include
yourself.
Order Born
First Name
Age
1.____________________________
2.____________________________
3.____________________________
4.____________________________
5.____________________________
6.____________________________
7.____________________________
_________
_________
_________
_________
_________
_________
_________
Male or Female
(Circle M or F)
M
M
M
M
M
M
M
F
F
F
F
F
F
F
Check one:
Full Half
_____ ______
_____ ______
_____ ______
_____ ______
_____ ______
_____ ______
_____ ______
Step
______
______
______
______
______
______
______
9.
If you answered question 8, which brother or sister did you consider yourself closest to
in growing up? Write the number of the one (listed above in question 8) here:___________________
10.
If you answered question 8, which brother or sister did you feel you had the most
trouble with in growing up? Write the number of the one (listed above in question 8) here:
_______________________
Or, if you had one sibling, please describe degree of closeness you experienced with him/her, e.g. very
close, close but competitive, not very close/often fighting, etc.
__________________________________________________________________________________________________________________
Additional comments about brothers or sisters:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
11.
Which of these words describe you as a child up to age twelve? Circle the number of all
that apply.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Awkward
Aggressive
Active
Calm
Emotional, shows feelings
Friendly
Frightened
Happy
Confident
Irresponsible
11.
12.
13.
14.
16.
16.
17.
18.
19.
20.
Nervous, easily upset/stressed
Outgoing
Shy
Serious
Happy-go-lucky
Rebellious
Temperamental
Stubborn
Unhappy
Other: ________________________________________
5
12.
Which of these were problems for you as a child up to age fifteen? Circle the number of
all that apply.
1.
Getting along with mother
2.
Getting along with father
3.
Getting along with stepmother
4.
Getting along with stepfather
5.
Getting along with sibling(s) [brother or sister]
6.
Getting along with peers
7.
Getting along with teachers
8.
Getting along with other relatives
9.
Bullying or bossy or teasing other kids
10.
Being bullied, bossed by or teased by other kids
11.
Trouble making friends
12.
Trouble keeping friends
13.
Getting in trouble with the police
14.
Having no friends
15.
Friends telling me what to do---too much of a follower
16.
Friends wanting me to tell them what to do
17.
Friends too much older than me
18.
Friends too much younger than me
19.
Friends who get in too much trouble
20.
Trouble with neighbors or people in town
21.
None of the above
13. Which of these were problems for you as a child up to age fifteen? Circle the
number of all that apply. If there is more than one part to the item, check which parts
apply to you in the blanks provided [see as in item 25]
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
1 3.
14.
15.
16.
17.
18.
19.
20.
Bed-wetting or soiling
Afraid to be left alone or left at school
Fears of things, e.g., animals, the dark, closed places, or ____________________________________________
Having feelings hurt by others
Nightmares
Excessive worries
Medical problem – specify:______________________________________________________________________________
Handicap -specify: _______________________________________________________________________________________
Nerves or nervous habits
Felt I was a burden to my parents
Overweight
Underweight
Nail biting
Fear of losing my parents
Worry about being sick or injured
Temper tantrums
Being overly stubborn and unreasonable
Experienced serious illness or injury resulting in hospitalization
Ran away from home two or more times, or, ran away one time and never returned
[If a girl] People said I was too much of a tomboy
6
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
14.
1.
2.
3.
4.
5.
6.
7.
[If a boy] People said I was too sissy
Setting fires
Trouble with lying
Physically abused by parent, relative, or caretaker
Sexually abused by parent_, relative_, family friend_, or caretaker
Sexually abused by other known adult_____ or unknown adult_______
Stealing without confronting the victim face to face, did this more than one time
Stealing with confrontation of the victim, such as purse-snatching or robbery, once or more
Used a weapon in more than one fight
Teased animals on one or more occasions, resulting in hurting or frightening them
Deliberately defaced or destroyed someone's property
Wished I was the opposite sex
Started physical fights often
Adopted and wasn't told _ or didn't have information about my birth parents_ or had other
problems due to adoption_
Sister_ or brother_ preferred by parent
Clinging to parent caretaker, difficult to separate or be left alone or at school
Clumsy or uncoordinated in sports/games
Criticized too much
Cultural differences of my family and others
Frequent moves or changes in schools
Gangs
Latchkey kid, left alone too much
Height problem, too tall _ or too short_
Hyperactive or inattentive
Physically unattractive
Pregnancy in myself_ or my girl friend_
Religious training lacking_ or overly rigid_
Physical handicap
Step-parent problem
Stuttering/stammering or other speech problem
Thumb-sucking
Eating disorder symptoms, e.g. Binging on food _ Self-induced vomiting to keep from gaining
weight _ Use of laxatives to keep from gaining weight _
Not liking or bored with school
Other: __________________________________________________________________________________________________
None of the above Additional comments about any listed or other childhood problems:
Write here your father's main occupation: _____________________________________________________
Circle the general type(s) of work he did below.
Skilled labor [such as mechanic, machinist, carpenter]
Unskilled labor [such as day laborer, temporary jobs]
Skilled craftsman [such as cabinet maker, jeweler]
Professional [minister, teacher, physician, RN nurse, accountant]
Sales person
Officer worker [clerical, lower level office manager]
Military
7
8.
9.
10.
11.
12.
13.
14.
15.
Government service [civil service]
Business manager or owner
Unemployed much of the time in my childhood
Disabled for a significant amount of time in my childhood
Homemaker most of the time during my childhood
Factory worker
Farming/agriculture
Not applicable [no father or father substitute]
15.
Write here your mother's occupation: _____________________________________
Circle the type(s) of work she did below.
1.
Skilled labor [such as seamstress, beautician, LPN nurse, phone operator]
2.
Unskilled labor [such as house cleaning, babysitting]
3.
Skilled craftsman
4.
Professional [such as RN nurse, teacher, physician, accountant]
5.
Sales person
6.
Office worker [clerical, lower level office manager]
7.
Military
8.
Government service [civil service]
9.
Business manager or owner
10.
Unemployed outside the home much of my childhood
11.
Disabled much of the time during my childhood
12.
Homemaker most of the time during my childhood
13.
Factory worker
14.
Farming/agriculture
15.
Not applicable [no mother or mother substitute]
16.
What did your parents (or caretakers) argue about?
Circle the number of all items that apply.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Discipline of the children
Money/how money was spent, and/or gambling
Relatives interfering/in-law problems
Drinking or drugs
Sex/affairs with others
Jealousy
Not taking care of the home
Not being a good provider/not having enough money
Previous spouse
Never argued in front of children
Avoided confrontation/ignored problems
Other, specify:_________________________________________________
Not applicable [parents never had a relationship at all]
8
17.
How would you describe your father’s usual style of discipline? Circle the number of one
choice only.
1.
Overly strict, rigid, harsh 4.
Lenient, liberal
or abusive
5.
Lax, did not pay attention
2.
Fairly strict
6.
Inconsistent
3.
Fair
7.
Unpredictable
18.
How would you describe your mother's usual style of discipline? Circle the number of
one choice only.
1.
Overly strict, rigid, harsh 4.
Lenient, liberal
or abusive
5.
Lax, did not pay attention
2.
Fairly strict
6.
Inconsistent
3.
Fair
7.
Unpredictable
19.
1.
2.
3.
4.
5.
How would you rate your own Intellectual abilities? Circle the number of one item only.
Mentally slow, slow learner
Below average, learning disabilities
Average
Above average
Superior/gifted
20.
What grades were you held back? Circle all that apply:
None KG 1 2 3 4 5 6 7 8 9 10 11
21 . If you quit school, circle the last year of school you
completed in full: 6 7 8 9 10 11 12
22 . Did you have any problems with any of the following in school?
Circle the number of all that apply.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Trouble learning math
Trouble with reading
In special education, slow learning, or learning disabled classes
Trouble with other kids teasing or making fun of me more than other kids
Getting into fights with other kids
Getting into trouble with teachers
Getting in trouble with the principal being suspended_ or expelled _
Ditching school truant more than once
Staying home sick more than average
Staying home to take care of responsibilities in the family
Really disliking certain teachers
Being disliked by some teachers
Being disliked by other kids because of being "teacher's pet"
Forgetting to do homework
Having no help from anyone with homework
Being required to go to continuation school
Feeling strongly pressured to achieve at high levels
9
23.
How far did you go in school? Circle the best answer and fill in the blanks where more
information is requested.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Did not finish high school and did not get GED
Quit high school and completed GED
Completed high school but did not get diploma
Completed high school and got diploma in 19___.
Attended vocational or trade school for _ years
Attended business school for ___ years
Attended _ semesters of college [One semester = 12 or more semester hours of credit or 16
quarter hours of credit]
Graduated from 2 year-college -AA degree: From where? ________________________________________
Graduated from 4-year college -BNBS degree: From where?______________________________________
Completed graduate work but no degree awarded: From where? ______________________________
Earned and awarded a master's degree in _____________________________
Earned and awarded a doctoral degree in ______________________________
24.
In general, what grades did you make in school or college in your last three years?
1 . ______Many D's and F's
2._______Mostly D's and C's
3._______Mostly C's
4._______Mostly C's and B's
5._______Mostly B's and A's
6._______Mostly A's
Additional comments about your experiences at school: ____________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
25.
At what age did you leave home to be on your own for the first time? ____________________
26.
After leaving home the first time, did you return to live at home with your parent(s) or
caretaker(s) again? No ___Yes____ At what ages?______________________________________________________
Why did you return? _____________________________________________________________________________________
______________________________________________________________________________________________________________
27.
1
2
3
4
5
6
7
Rate your family's Income/economic level during your childhood and teenage years:
Homeless/and or no regular income
Poverty level/received welfare
Working class
Middle class
Upper middle class/professional level
Wealthy
. Not applicable [not raised in a family but raised in an institution]
10
28.
1.
2.
3.
4.
5.
How often did your family experience financial problems?
Never that I am aware of
Occasionally
Often
Constantly
Not applicable [not raised in a family]
29.
Did your parents or brothers and sisters experience any of the following problems
during your growing up years or later:
Problem Area:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Trouble with alcohol
Trouble with drugs
Serious health problem
Mental illness
Arrested
Gone to Jail/prison
Left the home
Trouble holding a job
None of the above
30.
Have you ever served in the military? No
31 .
Which branch did you serve in?
1.
2.
3.
4.
5.
Family Member:
Mother/Father/Brother/Sister
______ ______ _______ _______
______ ______ _______ _______
______ ______ _______ _______
______ ______ _______ _______
______ ______ _______ _______
______ ______ _______ _______
______ ______ _______ _______
______ ______ _______ _______
______ ______ _______ _______
Yes
If no, skip to question 38.
Air Force
Army
Coast Guard
Navy
Marines
32.
How long did you serve?
1.
Did not finish basic training
and/or less than three months
2.
More than 3 months but less than one year
3.
Fair
4.
Two to three years
5.
Four years
33.
What was the highest rank you attained?
4.
5.
6.
7.
4 – 6 years
6 – 10 years
10 + years
Retired from military
[If enlisted:] Basic trainee E-1 E-2 E-3 E-4 E-5 E-6 E-7 or higher
[lf officer:] 01 02 03 04 05 or higher
11
34. Were you ever "busted" or reduced in rank?
No__________
Yes__________
35. If you were ever reduced in rank, what was your rank before being busted? __________
Your rank after being busted? __________
36. What kinds of problems did you experience while in the military? Circle all that apply.
1.
Getting used to following rules and regulations
2.
Taking orders
3.
Was reprimanded by my superiors for my conduct
4.
Had to perform special duty because of my conduct
5.
Did time in the stockade/brig
6.
Was court-martialed
7.
Went AWOL, __________ times
8.
Got homesick
9.
Saw a mental health counselor or psychologist/psychiatrist for evaluation only
10.
Saw a mental health counselor or psychologist/psychiatrist for counseling and
treatment
11 .
Was hospitalized due to medical problems
12.
Was hospitalized due to mental or alcohol/drug problems
13.
Had problems with my nerves
14.
Used alcohol to excess
15.
Used drugs
16.
Got in fights with people in the barracks
17.
Got in fights with people off base
18.
Trouble with people of different races or background
19.
Combat-related stress
20.
Trouble adjusting to overseas duty
21 . None of the above
Additional comments about your experiences in the military:
_____________________________________________________________________________________________________
37. What were the terms of your discharge?
1
Still on active duty. or [if never active duty] still in active reserves
2
Completed active duty and continuing on active reserves
3
Honorable discharge
4
General discharge
5
Discharged because not suitable for military service or could not adapt to the service
6
Discharged with a medical or psychiatric disability [Was awarded __% disability]
7
Bad conduct discharge
8
Dishonorably discharged
38.
Are you presently employed? No _____ Yes_____
Full-time _____ Part-time _____ Hours/week _____
Amount earned per hour $ _____ or per day $ _____
Amount earned per week $ _____ after taxes
12
39.
How many different jobs have you held in the past three years?
___ 0 ____ 1 ____ 2 ____ 3 ____ 4 ____ 5 ____ 6 ____ 7+
40.
If not employed, how long has it been since you were employed full-time? (If
you are in jail or in the hospital, do not count that time.)
a. Less than two weeks
b. Less than a month
c. Less than three months
d. More than three months
e. More than six months
f. More than 1 year
g. More than 3 years
h. More than 5 years
i. More than 10 years
j. Not applicable (I am employed)
41. Have you ever had, or do you currently have any problems in the area of work?
Include any jobs in your answer, including military. No __ Yes __
If yes, what kind of work problems? _____________________________________
______________________________________________________________
42.
job?
a.
b.
c.
d.
e.
f.
g.
h.
i.
If you are currently employed, how long have you been working at this
43.
Have you ever had any of the following work-related problems? Include
any military jobs as well as civilian experiences.
Repeated absences not due to illness in self or family
Monday morning hang-overs that resulted in calling in sick
Accused of theft or mishandling of money on the job
Let go because of repeated lateness or absence for any reason
Worked in an “under the table” job
Quit a job suddenly without giving notice
Repeatedly “laid off” because of lack of work or having no seniority
Unable to advance or progress in job pattern
Feeling like giving up because making too little money
Having to hold down more than one job to make enough money to live on
Having trouble dealing with customers or clients on the job
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
Less than six months
6 months to one year
1-2 years
2-3 years
4-5 years
6-10 years
11-15 years
16-20 years
21 or more years
13
l. Having trouble or conflict with one or more co-workers
m. Having a boss or supervisor who didn’t like me or hassled me
n. None of the above
44.
How many times in your life have you been fired or terminated from a
job because they were unhappy with you in some way? (Do not count “lay-offs”
from temporary jobs, or from construction or other normal terminations that
are not “for cause.”)
a. Never
b. One time
c. Twice
d. Three times
e. Four or five times
f. Six or more times
g. Not applicable (never held a job)
45.
How many times in you life have you quit a job because of disagreements
with a boss, supervisor, or co-workers?
a. Never
b. One time
c. Twice
d. Three times
e. For or five times
f. Six or more times
g. Not applicable (never held a job)
Additional comments about work problems: ________________________________
______________________________________________________________
______________________________________________________________
46.
Since starting full-time work, what is your longest non-work period of
time?
a. Less than one week
b. Less than one month
c. One to two months
d. Between 2 and 6 months
e. 6 months to a year
f. One to two years
g. Two to three years
h. Three to five years
i. Five to ten years
j. More than ten years
k. Not applicable
47.
a.
b.
c.
d.
Have you ever:
Drawn unemployment
Been on Worker’s Compensation
Been on SSI
Been on VA disability
14
e. Been medically retired
f. Been on welfare, or Aid to Dependent Children
g. None of the above
48. What kind of work have you done in the past or present? Circle all that apply.
a. Homemaker
b. Professional level (RN nurse, accountant, teacher, etc.)
c. Owner of own business
d. A skilled craftsman (cabinet maker, jeweler)
e. Office worker (clerical, secretarial, office manager)
f. Sales person
g. Skilled labor (plumber, carpenter, brick-layer, does not include assistant or trainee)
h. Unskilled labor (such as day laborer, factory work, babysitting, housecleaning)
i. Government service (civil service)
j. Personal service (hair stylist, maid, butler)
k. Executive (of own company or middle-level manager for a larger company)
l. Military enlisted
m. Military officer
n. Other: _____________________________________________________
o. Have never worked in an employed capacity
p. Have worked only in a volunteer capacity
Of all your jobs or volunteer work, which do you consider your best job and why?
Of all your jobs, which do you consider your worst job and why?
49.
If not employed or going to school at present, what are your future
career plans? What is preventing you from working right now and how are
you attempting to overcome these problems?
15
50.
Do you plan on further education or training or any kind of career
change? Please explain briefly.
51. When was the last time you used any of the following drugs. Check if you’ve
never used it. If you’ve used it at any time, indicate by checkmark how long
ago this usage was.
Drug:
Never
Last
3-12 mo.
1-2 yrs.
2+ yrs.
3 mo.
ago
ago
ago
1. Amphetamines/ _____
speed/uppers/
diet pills
_____
_____
_____
_____
2. Barbiturates/
downers
_____
_____
_____
_____
_____
3. Cocaine
_____
_____
_____
_____
_____
4. Heroin
_____
_____
_____
_____
_____
5. Marijuana
_____
_____
_____
_____
_____
6. PCP
_____
_____
_____
_____
_____
7. LSD/other
hallucinogens
_____
_____
_____
_____
_____
8. Quaaludes
_____
_____
_____
_____
_____
9. Pain Pills
_____
_____
_____
_____
_____
10. Tranquilizers
_____
(Valium, or other
prescribed drugs)
_____
_____
_____
_____
11. Gasoline/
_____
solvents/aerosols
(inhalation to get ‘high’)
_____
_____
_____
_____
52. What prescribed medications or street drugs have you used in the last 24 hours?
_________None
_________I have been prescribed & used the following: ________________________________________
____________________________________________________________________________________________
_________Other drugs I have used were:_________________________________________________________
16
53 a. Check which of the following drugs has ever been a problem for you. Problem drug
usage is defined as any usage that interferes with or causes problems in social relationships,
including family, or interferes with your ability to work or to get/keep a job or leads to an
arrest or accident.
Drug:
Never a
problem
Some
problem
Big
problem
1. Amphetamines/
speed/uppers/
diet pills
2. Barbiturates/
downers
_____
_____
_____
_____
_____
_____
3. Cocaine
_____
_____
_____
_____
4. Heroin
_____
_____
_____
_____
5. Marijuana
_____
_____
_____
_____
6. PCP
_____
_____
_____
_____
7. LSD/other
hallucinogens
_____
_____
_____
_____
8. Quaaludes
_____
_____
_____
_____
9. Pain Pills
_____
_____
_____
_____
10. Tranquilizers
(Valium, or other
prescribed drugs)
_____
_____
_____
_____
11. Gasoline/
_____
solvents/aerosols
(inhalation to get ‘high’)
_____
_____
_____
Additional comments about any present or past drug problems: __________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
17
53 b. What routes of administration of drugs you indicated in questions 51 and 53a were used:
Pills/
oral
Sniff/
snort
Smoke
IV
1. Amphetamines/
speed/uppers/
diet pills
2. Barbiturates/
downers
_____
_____
_____
_____
_____
_____
_____
_____
3. Cocaine
_____
_____
_____
_____
4. Heroin
_____
_____
_____
_____
5. Marijuana
_____
_____
_____
_____
6. PCP
_____
_____
_____
_____
7. LSD/other
hallucinogens
_____
_____
_____
_____
8. Quaaludes
_____
_____
_____
_____
9. Pain Pills
_____
_____
_____
_____
10. Tranquilizers
(Valium, or other
prescribed drugs)
_____
_____
_____
_____
11. Gasoline/
_____
solvents/aerosols
(inhalation to get ‘high’)
_____
_____
_____
53c. Check or complete any of the following that apply to your current or past drug or
alcohol usage:
__________ Age of first drug use
__________ Age of first alcohol use.
__________Treated for drug or alcohol abuse on outpatient basis
__________"Detoxed" or withdrawn from alcohol or drugs on outpatient basis
__________"Detoxed" or withdrawn from alcohol or drugs on inpatient basis
__________Treated for drug or alcohol abuse on inpatient/residential basis
__________Drug abuse problem followed normal prescribed drug use for medical problem or surgery
__________Drug abuse problem developed because drugs were available due to my occupation,
e.g. hospital employee, nurse
__________Drug abuse problem developed because of availability in the family
18
__________Refused job because of failed drug or alcohol screening
__________Lost employment due to drug or alcohol problem
__________Lost relationships or marriages due to drug or alcohol problem
__________Went through drug or alcohol withdrawal on my own
__________Quit drugs or alcohol totally for a period of time, then used again
__________Spouse or parent thought I had a drug or alcohol problem but I don't agree that I did
__________Spouse or parent thought I had a drug or alcohol problem and I do agree that I did
__________Lost temporary or permanent custody of a child because of alleged alcohol or drug problems
on my part
54.
Using the last three months, please estimate on the average, how often do you drink
alcohol? If you have quit drinking, how often did you drink alcohol during the last three
months of usage? If you quit drinking, when was the last time you had a drink?
1.
Never in my life
6.
Once a week
2.
Never (I used to but I quit) 7.
2-3 times a week
3.
Once or twice yearly
8.
3-5 times a week
4.
Once monthly
9.
Every day
5.
One to 3 times monthly
If you quit drinking, when was the last time you had a drink?___________________________________
_________________________________________________________________________________________________________
55.
If you drink alcohol currently, on the average, when you drink what kinds and how
much do you consume? Circle types and amounts that are typical for you to drink in an
evening. Check "and___” if you combine different kinds of drinks and "or____" if you
typically use one or the other.
Beer
and/or
1-2 beers (12 oz.)
3-4 beers
5-6 beers
7-12 beers
13+ beers
56.
Wine
and/or
1-2 glasses (4oz each)
3-4 glasses
5-6 glasses
1 fifth or more
2 fifths +
Liquor
1-2 mixed drinks (1oz each)
3-4 mixed drinks
5-6 mixed drinks
1/2 – 1 pint
1pint-1 fifth
1 fifth +
If you have ever used alcohol, what is the most alcohol you have ever consumed in one
24·hour period? Circle types and amounts that would be applicable in your case. Check
"and____" if you combine different kinds of drinks and "or____" if you typically use one or
the other.
Beer
and/or
Wine
and/or
Liquor
1-2 beers (12 oz.)
1-2 glasses (4oz each)
1-2 mixed drinks (1oz each)
3-4 beers
3-4 glasses
3-4 mixed drinks
5-6 beers
5-6 glasses
5-6 mixed drinks
7-12 beers
1 fifth or more
1/2 – 1 pint
13+ beers
2 fifths +
1pint-1 fifth
1 fifth +
19
When would have this "most ever" alcohol usage been? Give approximate date: _________________
57.
How much alcohol have you had to drink in the last 24 hours prior to today's exam?
(Circle all that apply.)
Beer
1-2 beers (12 oz.)
3-4 beers
5-6 beers
7-12 beers
13+ beers
58.
Wine
1-2 glasses (4oz each)
3-4 glasses
5-6 glasses
1 fifth or more
2 fifths +
Liquor
1-2 mixed drinks (1oz each)
3-4 mixed drinks
5-6 mixed drinks
1/2 – 1 pint
1pint-1 fifth
1 fifth +
Have you ever:
Been picked up for drunk and disorderly conduct or drunk in public?
Been stopped driving under the influence?
Been arrested/convicted for driving under the influence?
Had an accident while driving after drinking, even though not charged for drinking?
Had two or more DUl's?
Had an argument or fight with a spouse, family member, your children, or a friend while
drinking?
7. Had an argument or fight in a public place with someone you knew only slightly while
drinking?
8. Engaged in sex with someone you knew only slightly while drinking?
9. Had alcohol or drug-related "black-outs" where you did not remember clearly for a period of
hours or longer?
10. Had episodes of "DTs" or hallucinations [visual, auditory, tactile] during or following use of
alcohol or drugs
11. Entered a hospital for purposes of withdrawing from alcohol or drugs
12. Used alcohol to manage periods of overwhelming anxiety or fears or to temporarily deal with
feelings of social or sexual discomfort_ or to temporarily deal with feelings of depression_
13. Used drugs to enhance alertness or creativity in order to complete school or work projects
14. None of the above
1.
2.
3.
4.
5.
6.
Comments about any alcohol or drug-related problems: ______________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
59. If you have ever used alcohol, estimate the number of times you have been Intoxicated in
your life, e.g., have felt the effects to a degree that your behavior, judgment, or movements
were affected. To estimate, take your average number of times per week in which
intoxication might occur and multiply by 50 to get the total for a given year, e.g., once a
week for a year = 50 times, twice a week = 100 times In a year. Multiply total times number
of years you've used alcohol, e.g. 2 years @ 25 times each, 5 years @ 50 times each, for a
total of 300 times.
20
1.
2.
3.
4.
5.
6.
60.
Never
1-2 times
less than 5 times
6-10 times
11-25 times
26-50 times
7.
8.
9.
10.
11.
12.
51-100 times
101-200 times
201-500 times
501-1000 times
1001-2000 times
More than 2000
If you believe that you have or ever have had an alcohol problem, at what age did it first
begin?
______Under age 12 ______ Age 22-25
______ Age 51-60
_____ Age 13-15
______Age 26-30
______ Age 61-70+
_____Age 16-18
_____ Age 31-40
______ Never became a problem
____ Age 19-21
_____ Age 41-50
61.
Have you ever [circle the number of all items that are applicable to you, and check the
blanks of the parts of the items that apply to you]:
1. Gambled to try to win back earlier gambling losses?
2. Gambled on borrowed money____ or money needed for living expenses______?
3. Defaulted on debts--failed to make late payments _____or had property repossessed_____?
4. Declared bankruptcy?
5. Had credit cards revoked?
6. Lived without a fixed address for a month or more, living with various friends_ or on the
street_?
7. Driven while intoxicated repeatedly, without being arrested?
8. Been accused of [or engaged in] child neglect____, physical abuse______, sexual abuse_____ ,or
abandonment of a child________ : or had a child placed in foster or institutional care_ or lost
parental rights_?
9. Failed to pay regular child support?
10. Failed to maintain regular contact with a child of your own who was living with another party
[except when ordered to stay away by the Court]?
11. Been accused of failing to maintain your child with adequate food, clothing, shelter, or medical
care?
12. Been unable to maintain your child with adequate food, clothing, shelter, or medical care?
13. Had to leave your child nine years of age or younger without a babysitter while going away for
several hours or more during the day or for any amount of time in the evening?
14. Used an alias or AKA instead of your real name?
15. Been arrested as a juvenile _______ times?
16. Been arrested as an adult ________times?
17. Picked up for warrants _______times?
18. Served time in Jail ________months?
19. Served prison time _______years?
20. Been accused of or actually involved in physical fights with a spouse _______or parent _________
brother ________ or sister_________?
21. Had police intervene in family disputes?
22. Had problems with impulse spending_____ or buying too much on credit_______?
23. Supported yourself partially or completely by illegal means, e.g., fencing stolen goods ______,
drug sales________, prostitution________ or other means _______?
21
62. Have you ever had any of the following occur?
1
2
3
4
5
6
7
8
I have been sued times.
I have filed a civil law suit aside from divorce action times.
I have filed a worker's compensation claim _ times.
I have filed a personal injury suit _ times.
I have been on state disability _times.
I have been on Social Security disability since ---:-___
I have had an immediate family member who filed a personal injury suit.
None of the above
Comments on any of the above problems: __________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
63.
What is your current marital status? Circle all that apply:
1. Single-never married
2. Involved in an intimate relationship with a person of the same sex
3. Involved in an intimate relationship with a person of the opposite sex
4. Living with a person of the same or opposite sex
5. Living with a person of the opposite sex in an established "common law" relationship
6. Separated, with one marriage in total
7. Separated, with two or more previous marriages in total
8. Divorced, with one marriage in total
9. Divorced, with two or more previous marriages in total
10. Married, one time only
11. Remarried or common law after one or more divorces
12. Widowed
13. Marriage annulled
14. Remarried after one marriage annulled
15. Remarried after being widowed
64.
If you have been married, how many times total have you been married? Include
common law [living together] relationships: 0 1 2 3 4 5 6+
65.
If you have been married more than once, indicate by number of marriage (e.g., #1, #2,
#3) in the blanks, how each one ended {e.g., #1 by death, #2 by divorce}:
Annulment ___________ Divorce ___________ Death ___________
66.
How many children do you have by each marriage or relationship? For example, write
in "2" if you have 2 children by the first marriage, write in "1" if you have one child by
the second marriage, and so on. Include any common law relationships.
1. ___________
_____________
___________
_____________
22
2. ___________
_____________
___________
_____________
3. ___________
_____________
___________
_____________
Are you currently having any problems with any of your children?
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
67.
How long have you been living continuously with your current partner? ___________________
Or, not applicable ______________________________________________________________________________________
68.
How would you describe your current partner/significant other or boy friend/girl
friend?
1. ______Warm
15. ______Perfect
2. ______Unhappy
16. ______Indifferent
3. ______Distant
17. ______Argumentative/angry
4. ______Uncaring
18. ______Boring
5. ______Happy
19. ______Stimulating
6. ______Unpleasant
20. ______Unforgiving
7. ______Enjoyable
21 . _____Tense
8. ______Abusive
22. ______Affectionate
9. ______Fault-finding
23. ______Able to compromise/work it out
10. _____Short-tempered
24. ______Demanding
11. _____Faithful
25. ______Other:_________________________________________
12. _____Predictable
26. ______ Not applicable [no partner at present]
13. _____Well-balanced
14. _____Moody
69.
How would you describe your previous partner or former boy friend or girl friend? If
you have broken up with or separated or divorced this individual, please describe
him/her up to the time prior to problems developing that led to the break-up.
1. ______Warm
15. ______Perfect
2. ______Unhappy
16. ______Indifferent
3. ______Distant
17. ______Argumentative/angry
4. ______Uncaring
18. ______Boring
5. ______Happy
19. ______Stimulating
6. ______Unpleasant
20. ______Unforgiving
7. ______Enjoyable
21 . _____Tense
8. ______Abusive
22. ______Affectionate
9. ______Fault-finding
23. ______Able to compromise/work it out
10. _____Short-tempered
24. ______Demanding
11. _____Faithful
25. ______Other:_________________________________________
12. _____Predictable
26. ______ Not applicable [no partner at present]
13. _____Well-balanced
14. _____Moody
23
70.
What are your living arrangements? Circle the item, which applies to you and check
which part of the question describes your situation.
1.
2.
3.
4.
5.
6.
7.
Living with relatives in their home
Living with friends in their home
Renting a home/alone or with partner &children
Renting an apartment/alone or with partner & kids
Buying a home/alone or with partner & kids
Own my own home
Living in a military barracks _____ or college dorm _____ board and care ______ residential
treatment program _____YMCA or YWCA _____Other_________________________________________
8. Renting a motel room by the week
9. Renting a motel room by the day when I can do so
10. Sometimes living on the street
11. Presently hospitalized or in jail
71 .
How often do [or did} you and your partner argue?
1. ______Not applicable
5. _____ Several times a week
2. ______Never or Rarely
6. ______Daily
3. ______Once a month
7. ______Several times a day
4. ______Once a week
8. ______Constantly
72.
If you are in a relationship, circle all of the following problems, which apply to you.
Check or fill in additional information where indicated.
Sexual problems/partner or self
Affairs that have interfered with our relationship: My affair ____My partner's affair____
Domestic violence: Hitting ____Shoving ____Slapping ____Choking ____Threatening__________
Other ________________________________
Trouble with the behavior of our children
Continued problems with my ex-spouse or my partner's ex-spouse
In-law or extended family problems
Other family problems: ________________________________________
1.
2.
3.
4.
5.
6.
7.
73.
1
2
3
4
5
How well do you feel your partner fulfills his/her role with you?
Very well
Fairly well
Only fair
Very poorly
Not applicable
Any additional comments about the quality of your current or past relationships:
____________________________________________________________________________________________________________
__________________________________________________________________________________________________________
24
74. What interests do you and your partner have in common? Circle all that apply.
1. ______None
9. ______Television/movies
2. ______Children
10. ______Religious activities
3. ______Work-related
11. ______Club Activities
4. ______Sports
12. ______Talking
5. ______Hobbies or crafts
13. ______Games
6. ______Politics
14. ______Camping
7. ______Theatre
15 . _____Hunting/fishing
8. ______Socializing/friends
16. ______Other:_____________________________
17. ______Not applicable (no partner)
Comments about current marital relationship or previous ones:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
75.
Which of the following have you experienced in the past two years?
1. Separation from partner
2. Marriage
3. Marital reconciliation
4. Gain of a new family
5.Business readjustment status
6. Change to different
7. Sex difficulties
8. Change in health of
9. Death of spouse/partner
10. Pregnancy/birth of child
76.
1.
2.
3.
4.
5.
77.
11. Retirement
12. Fired at work
13. Divorce
14. Death of close friend member
15. Change in financial
16. More or less argument line of work with
partner
17. Jail term
18. Court family member proceedings
19. Civil court case or parent/child
20 . Filed for bankruptcy
21. Major iIIness/injury
22. Arrest(s)
23. None of the above
How would you rate your ability to cope with changes and to cope with life in general?
Very good
Generally good
Fair
Inconsistent
Poor
How would you describe yourself as a person?
1
Active, full of energy
11 . Affectionate
2
Aggressive or pushy
12.
Shy
3
Assertive, stand up for myself
13.
Withdrawn
4
Carefree, happy-go-lucky
14.
Temperamental
25
5
6
7
8.
9.
10.
Easygoing, laid back
Confident
Impatient, easily frustrated
Smart, intelligent
Stubborn
Friendly, outgoing
15.
Rebellious
16.
Responsible
17.
Predictable
18.
Unassertive
19.
Serious
20.
Low self esteem
21.
Other: _______________________________________
What I like about myself the best Is: _______________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
What I like about myself the least is: _______________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
What I would like to change about myself is: _________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
What I feel will never change about myself is: ________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
What surprises people the most about me once they get to know me Is: ____________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
What I am most proud of, thus far In my life, is: _____________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
My biggest mistake, thus far In my life, Is: _________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
26
78 a.
What do you consider to have been the best relationship with another person in your entire
life? This could be a relationship you had in childhood or in adulthood. What about the
relationship made it the best one? How long was this relationship, and if it ended, how did that
happen?
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
78 b. What do you consider to have been the worst relationship with another person in your entire
life? This could be a relationship you had in childhood or in adulthood. What about the
relationship made it the worst one? How long was this relationship, and if it ended, how did
that happen?
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
79.
How would you describe your current mental state or attitudes?
1
Tense
12.
Disappointed
2
Depressed
13.
Regretful
3
Forgetful
14.
Guilty
4
Sad or down
15.
Irritable
5
Worried and anxious
16.
Calm
6
Fearful of things
17.
Sacred of future
7
Angry
18.
Hyperactive
8.
Unenthusiastic
19.
Nervous
9.
Confused
20.
Happy
10.
Excited, looking forward
21.
Distrustful
11.
Busy, involved
22.
None of above
80.
Have you ever seen a counselor of any type (minister, family doctor, MFCC counselor,
psychologist, or psychiatrist? No _______ Yes ________
81.
If you have ever seen a counselor, please fill in the following information:
Approximate
Name of
For what reason?
Year (s)
doctor/counselor
1. _____
___________________________
________________________________________________
2. _____
___________________________
________________________________________________
3. _____
___________________________
________________________________________________
4. _____
___________________________
________________________________________________
5. _____
___________________________
________________________________________________
27
Were these counseling experiences helpful and positive, or not helpful and negative for
you? Or were they of no effect? Why? Please comment, listing your comments
corresponding to numbers in previous item.
1.
_______________________________________________________________________________________________
________________________________________________________________________________________________________
2.
_______________________________________________________________________________________________
________________________________________________________________________________________________________
3.
_______________________________________________________________________________________________
________________________________________________________________________________________________________
4.
_______________________________________________________________________________________________
________________________________________________________________________________________________________
5.
_______________________________________________________________________________________________
________________________________________________________________________________________________________
82.
Have you attended any kind of self-help group, e.g. AA, NA, OA, Children of Alcoholics,
sexual abuse survivors' group?
No _______Yes _______ If yes, for what period of time? _________________________________
Did .you find the experience(s) helpful, and if so how? [Or, if not, why not?]
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
83.
1
2
3
4
5
6
84.
1.
2.
3.
4.
5.
Have you ever experienced any of the following? Y (yes) or N (no), if yes please explain
Evaluation/testing for a job for which you were turned down ______________________________
Evaluation/testing for a worker's compensation or personal injury case where stress was a factor
_______________________________________________________________________________
Evaluation/testing for a court case of any type __________________________________________
Hospitalized involuntarily on a "5150" hold, approximately ____times ______________________
Hospitalized voluntarily for emotional problems, about _____ times ________________________
Committed to a hospital for emotional problems, about _____ times ________________________
Have you ever suffered any of the following or do any of the following medical conditions
apply to you? Circle all that apply and fill in the blanks for additional information as
requested.
Period of unconsciousness for less than one minute, indicate number of times___________
Period of unconsciousness for 1-5 minutes, indicate number of times _________________
Period of unconsciousness for 6-15 minutes, indicate number of times ________________
Period of coma, indicate how long: ___________________________
Seizures of any kind _______________________________________
28
6.
7.
8.
9.
10.
11 .
12.
13.
14.
15.
16.
17.
18.
19 .
20.
21.
22.
23.
24.
26.
27 .
28.
29 .
30.
31.
32.
33.
34.
35 .
36 .
37.
38 .
39.
40.
41 .
42 .
43.
Loss of periods of time I could not account for lasting for hours or longer
Paralysis and inability to move or speak
Brain concussion, with or without unconsciousness
Drug toxicity or allergic reaction
Drug overdose
Serious illnesses or accidents resulting in hospitalization. When? ___________________________
Diabetes
Thyroid disorder
Heart, circulatory or blood pressure problems
Digestive or intestinal problems
Neurological disease
Problems with vision
Problems with hearing
Problems with balance and equilibrium or balance
Skin problems
Broken bones
Orthopedic problems, e.g. diseases of bones or joints
Dental problems ___________________________________________
Cuts or wounds requiring medical attention
If female, menstrual cycle irregularity
If female, premenstrual or menstrual problems
If female, number of times pregnant: ______Number of miscarriages: ______
Number of abortions: ___________ number of live births: _____________
If female, any problems during any pregnancy
If female, fertility problems
If female, pain with intercourse
If female, inability to "lubricate"
If female, fear and avoidance of gynecological exams
If male, medical problem or medication or drug use interfering with attaining and maintaining
an erection
If male, any prostate or urinary problems
Male or female, ever having a venereal disease
Numbness or loss of feeling in any part 01 the body
Fear and avoidance of going to the dentist
Constantly worry about getting sick
Fear of getting certain diseases
Fear of obtaining appropriate medical care
Not wanting to take medications prescribed by doctor
Having problems for which I went to doctor and was told it was "all in my head"
29
85.
Please check signs of the following symptoms or problems that you are experiencing
now, or for any significant period of time in your past life. Add any comments you think
are important. Use back of page if necessary.
Symptom
In the past
week
For a significant
period of time
in the past
Comment
a. Overactive or agitated
b. Increased activity
c. Anxious feelings
d. Sad or down
e. Apathetic & not caring about
anything
f. Avoiding people
g. .Eating too much
h. Eating too little
i. Hopelessness
j. Distractible, can’t
concentrate
k. Racing thoughts
l. Elevated or “high” feelings for
no reason
m. Irritability toward others
n. Hard to make decisions
o. Insomnia (can’t sleep) or
less sleep
p. Headaches
q. Back & neck pain
r. Loss of sex drive
s. Needing sexual release twice
or more per day
t. Constipation
u. Increased energy
v. Diarrhea
w. Angry
x. Loss of interest in activities
y. Decreased appetite
z. Trembling
aa. Nausea
bb. Feeling guilt & sorrow
cc. Suspicious or frightened of
others
dd. Moody
ee. Numbness in one or more
body areas
30
Symptom
In the past
week
For a significant
period of time
in the past
Comment
ff. Repetitive, disturbing
dreams or nightmares
gg. Lost or gained more than
ten pounds
hh. Worrying a great deal
ii. Feelings of inadequacy
jj. Feelings of discouragement
kk. Feelings of distrust
ll. Hearing voices that other do
not hear
mm. Seeing thing that other do
not see
nn. Paranoid or misreading
the intentions of others
oo. Feeling suicide
pp. Attempting suicide
qq. Feeling like hurting
somebody else
rr. Hurting someone else
(spouse, child, other)
ss. Feeling isolated from others
tt. “Flashbacks” (sudden, vivid,
distracting memories)
uu. Stomach problems
vv. Feelings that things are
“unreal”
ww. Memory problems
inferring with school/work
xx. Feelings that you are not
always in your body
yy. “Spacing out” (going away
in your mind)
zz. Attraction to people of
same sex
Aaa. Sexually promiscuous or
too casual or get involved too
quickly
Bbb. Unnecessary or over
frequent hand washing
ccc. Needing to “check” or
count things over and over
Ddd. Needing to repeat certain
activities over and over
31
Symptom
In the past
week
For a significant
period of time
in the past
Comment
Eee. Passing out
Fff. Extreme fatigue and loss of
energy
Ggg. Loss of periods of time
after drinking or drug use
Hhh. Attraction sexually to
children
iii. Bad, unpleasant memories
Jjj. Loss of religious faith
Kkk. Impotence or loss of
ability to have an erection or to
maintain an erection in order
to have sex
Lll. Premature ejaculation –
coming too soon when I have
sex
Mmm. Unable to “come” or
have sexual climax
Nnn. Doing thins sexually
which I later regret
Ooo. Waking up early in the
morning and can’t get back to
sleep
Ppp. Trouble controlling
temper
Qqq. Uncontrollable crying
Rrr. Can’t get started doing
things, or can’t finish the things
that I start
Sss. Loss of interest in work
Ttt. Anxiety attacks—
overwhelming anxiety, with
perspiration, trouble
breathing, panic
Uuu. Feeling withdrawn and
not wanting to communicate
with others
Vvv. Unresponsive or
disinterested sexual partner
www. Excessive masturbation
xxx. Need for pornographic
material or movies in order to
obtain sexual release
32
Symptom
In the past
week
For a significant
period of time
in the past
Comment
Yyy. Difficulty in resolving
grief after a loss by death
Zzz. Insufficient recreational
time or opportunities
Aaaa. Loss of time (memory)
that I can’t account for due to
drugs or alcohol, minutes to
hours I cannot recall
Bbbb. Cut off from a family
member due to disagreements
or other conflicts
Cccc. Continuous financial
difficulties
Dddd. Dizziness when
stressed
Eeee. Loss of temper
Ffff. Never having had an
interest in sex (lifelong)
Gggg. Partner too demanding
Hhhh. Needing to follow a
schedule or do things in a
certain way or else I become
anxious or upset
Iiii. Gaps in my memory, hours
to days, not accounted for or
due to alcohol or drugs
Jjjj. Gaps in my memory, days
to weeks, not accounted for or
due to alcohol or drugs
Kkkk. Feeling I was a stranger
to myself or as in a dream
Llll. Feeling part of my body
was foreign or disconnected
Mmmm. Feeling that my arms
or legs are bigger, smaller, or
changing in size
Nnnn. Heard myself talking,
but felt I was not choosing the
words
Oooo. Felt as if my words,
behavior or feelings were not
under my control—like a
puppet
33
Symptom
In the past
week
For a significant
period of time
in the past
Comment
Pppp. Felt as if my
surroundings or people around
me were unfamiliar or unreal
Qqqq. Felt as if there is a
struggle going on about who I
really am
Rrrr. Felt puzzled as to what is
real or not real in my
surroundings
Ssss. Felt like I was a child or
younger person
Tttt. Told my others that at
times I seem like a different
person
Uuuu. Felt confused as to who
I am
Vvvv. Found things in my
possession that seemed to
belong to me but I didn’t
remember how I got them
Wwww. Felt fear for my life
xxxx. Felt somehow
“possessed” or controller
Yyyy. Felt out of touch with
reality
Zzzz. Unable to carry out
necessary social, academic, or
work responsibilities due to
emotional incapacitation
Aaaaa. Scanning my
environment and unable to let
my guard down and feel
comfortable
Bbbbb. Felt my mood change
rapidly with no real reason
Ccccc. Felt as though I was
reliving the past
Ddddd. Having ongoing
dialogues or discussions with
myself
Eeeee. Handwriting changed
radically
Fffff. Jumpiness, easily
startled
34
Symptom
In the past
week
For a significant
period of time
in the past
Comment
Ggggg. Impulses to do thing I
would not ordinarily do
Hhhhh. Repeated nightmares
Iiiii. After a nightmare, finding
myself out of bed
Jjjjj. After a nightmare, not
knowing where I am
Kkkkk. After a nightmare, not
being able to “come out of it”
Lllll. Suddenly, feeling much
younger, childlike
Mmmmm. Afraid to leave the
house without someone with
me
Nnnnn. Afraid of driving
Ooooo. Afraid of being left
alone
Ppppp. Afraid of high places
Qqqqq. Afraid of closed places
Rrrrr. Afraid of meeting
people
Sssss. Afraid of no one taking
are of me
Ttttt. Afraid of germs
Uuuuu. Afraid of having a
panic attack
Vvvvvv. Too obsessive or
perfectionistic, can’t tolerate
small mistakes
Wwwww. Trouble making
friends
Xxxxx. Trouble keeping
friends
Yyyyy. Afraid I am attracted to
people of the same sex and I
don’t want to be gay
Zzzzz. Difficulty in carrying
out necessary social, academic
or work responsibilities due to
psychical incapacitation
Aaaaaa. Sleep walking
Bbbbbb. Sleep talking
35
Symptom
In the past
week
For a significant
period of time
in the past
Comment
Cccccc. Continuous
sleepiness/drowsiness during
the day
Dddddd. Confused &
disoriented upon waking from
sleep
Eeeeee. Night terrors—acting
like a nightmare, but not
recalling anything
Ffffff. Seizures or other loss of
awareness
Gggggg. Afraid of going to
sleep
Hhhhhh. Trashing and
movement during sleep
Jiiiiii. Specific routines,
patterns, in how thins must be
done
Jjjjjj. Trouble in arousing and
waking up
Kkkkkk. Too light sleep, too
easily awakened
86.
List names of all medications you are currently taking, and frequency per day as well as
dosages if known:
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
36
87.
At what age in your life do you believe your overall adjustment and functioning was at
your best? Describe briefly this time frame, and why you think this was your best time.
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
88.
At what age in your life do you believe your overall adjustment and functioning was at
your worst? Describe briefly this time frame and why you think this was your worst
time.
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
89.
Across your whole life, would you say that things have:
_______Generally gotten better?
_______Generally gotten worse?
_______Been "up" and "down" for no particular reason?
_______Been "up" and "down" due to___________________________________________________________________
90.
What are your usual spare-time or recreational activities?
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
91.
Have there been any changes in your usual spare-time or recreational activities recently? If,
yes, please describe.
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
92.
Are you suffering from any condition that might affect your evaluation today?
No _______ Yes _______ If yes, please describe: ________________________________________________________
37
93.
Have there been any very recent upsets, disturbing events, or changes in your life in the recent
past, aside from those you've already told us about that we should know about in order to
have the full picture today?
No Yes If yes, please describe:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
94.
Any additional information you wish to add or that you think need clarifications from items
you have completed in this questionnaire:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Please complete if your case is legally related: I certify that the above information is true and
complete to the best of my knowledge. If I have any questions or concerns, I have asked my
examiner and/or made a note.
Your name (typed or printed)_______________________________________________________________________________
Signature_______________________________________________________________________________Date: __________________
38