The
purpose of this questionnaire is to help suffering persons identify possible
root causes of physical, mental and emotional symptoms.
Name ___________________________ Date of birth __________ Today’s date________
Please
explain your current chief complaint or symptoms:
MEDICAL HISTORY
Have you received formal diagnoses of any kind?
Do you have a chronic physical pain or illness that
won't go away, or that Doctors cannot seem to cure?
Have you ever been under general
anesthesia? What for? When?
Have you ever lost a child, born
or unborn? If so, when?
Have you been told you have a hereditary
disease? What is it?
MENTAL HEALTH HISTORY
Do you suffer from anxiety or
panic?
Have you been diagnosed with another
psychiatric or mood disorder? Please explain.
Do your moods change quickly for
no apparent reason?
Do you have memory loss?
Do you have intrusive thoughts or feelings?
Do you ever feel that you are not alone?
Over time, have you developed addictions to food,
alcohol, drugs or behaviors you didn't have before?
Have you ever used drink or drugs
to the point of blackout (walking and talking, but not remembering a period of
time)?
Have you ever used drink or drugs
to the point of unconsciousness? List
dates the best you can.
Do you hear thoughts in your head that are not
yours?
Do you see people or things that others cannot? If so, please describe
Are you or have you ever felt suicidal?
History of Traumatic Experience
Have you been involved in loss-of-life events? When?
Has a loved one died, who had symptoms, personality
changes, habits, addictions like yours?
Have you been a victim of a violent crime?
Do you see a cycle of victimization in your life?
Did you suffer physical, sexual or emotional
abuse? When?
Were
you ever tortured physically, mentally or emotionally? When?
Behavioral
Are you accident prone or clumsy? If yes, please
explain
Do you sustain recurring injuries or symptoms in the
same area of your body? (Ex: always bumping your head, always twisting your
right ankle, always have a stomach ache, etc). Please explain.
Do people ever say that you did
or said something, but you have no recollection of doing or saying it?
Has anyone ever said that you
talk in your sleep?
Do you have insomnia?
Did you suddenly lose your
attraction to your mate, or decide to change your sexual orientation?
Do you feel repulsed by people of the same or opposite
sex?
Have you had a dramatic change in attitude or
beliefs?
Have you ever engaged in self-destructive behavior –
cutting your skin or hair, picking at your skin or face, battering yourself or
other things? When?
Circumstantial
Did your mother ever lose a child that you know
of? If so, when?
Were you a twin, but the other
baby didn’t survive?
Do you know anyone who has committed suicide? If so, who and when?
Are any of your symptoms similar
to those of a deceased family member or loved one?
Do you feel like someone has hexed you, or put a curse
on you?
Environmental
Have you ever toured or lived
near or fought in a battlefield or place of extreme decimation of human life?
Do you experience paranormal
activity in your home? Please explain.
Do you live near or spend time in
a cemetery for any reason?
Do you live near a hospital, convalescent home,
funeral home, church, etc?
Have you spent time in a hospital,
prison, convalescent home, treatment center - for work, to visit, or other
reasons? When?
Other
Is there anything else you’d like me to know?
