LIFE HISTORY QUESTIONNAIRE
The purpose of this questionnaire is to obtain a comprehensive picture of your background. By completing
these questions as fully and accurately as you can, you will facilitate your therapeutic program. This
questionnaire will save you both time and expense. You are requested to answer these routine questions
on your own time instead of using up your counseling time.
It is understandable that you might be concerned about what happens to the information about you
because much or all of this information is highly personal. Case records are strictly confidential. No
outsider, not even your closest relative or family doctor is permitted to see your case records without youâ
€™re written permission.
IMPORTANT: If you do not desire to answer a question, write “Do not care to answer�. Also, if a
question does not apply to you, simply write “N/A� in the space provided.
Date_______________
Name____________________________________________
Address__________________________________________
City_______________________________
State & Zip____________________ Phone_________________________
Age_____ Occupation_____________________________
Religion________________ Attendance: Regular Occasional Never (circle)
1) With whom are you now living? (List people, their names, ages & occupations. If they are students,
indicate what grades.)
2) How strongly do you want treatment for your problem? (Circle One)
Very much Much Moderately Could do without if necessary
You can help us save time by explaining in your own words some things about your problem. Please be as
specific as possible. A few particular examples of how the problem comes up would be valuable.
3) State in your own words the nature of your chief concern:_______________________
4) If your problem is something you think happens too often, state approximately how often it occurs, how
long it lasts and any other information you feel might be helpful in understanding your problem.
5) If your problem is concerned with something not happening as often as you would like, state what you
would like to see happening more often, how often you think it should occur, etc…
6) Are any of the people listed in question1 important in some way to your problem?
YES NO
If yes, please mention specific ways they have been involved, both good and bad points should be
mentioned if possible.
7) With whom have you talked about your problem?
8) Date and place of birth?__________________________________________________
9) Approximately how many times did your family move when you were young? ______
10) How many times have you moved since you left your parental home? ________
11) How old were who when you left your parent’s home? _______
12) What was your mother’s condition during pregnancy as far as you know?
13) Underline any of the following that apply to your childhood:
Night terrors; Bed wetting; Sleepwalking; Thumb-sucking; Nail-biting; Stuttering; Fears; Happy
childhood; Unhappy childhood.
14) Health during childhood?________________________________________________
15) List childhood illnesses:_________________________________________________
16) Health during adolescence:_______________________________________________
17) List adolescence illnesses: _________________________________________
18) Any physical disabilities?________________________________________________
19) How related to your present problem are health issues, past or present?____________
20) Your present height:______________ weight:___________
21) Any surgical operations? Please list them and at what age they occurred.
22) When was the last time you felt well, both physically and emotionally for a fair
amount of time?
________________________________________________________________________
________________________________________________________________________
23) Underline any of the following that apply to you: Headaches; Dizziness; Fainting spells; Palpitations;
Stomach trouble; No appetite; Bowel disturbances; Fatigue; Insomnia; Nightmares; Take sedatives;
Alcoholism; Feel tense; Tremors; Depressed; Suicidal ideas; Drugs; Unable to relax; Sexual problems;
Unable to have a good time; Don’t like weekends or vacations; Over ambitious; Shy with people;
Can’t make friends; Feel lonely; Can’t make decisions; Can’t keep a job; Inferiority feelings;
Home conditions bad; Financial problems.
Other___________________________________________________________________
24) Games and interests during childhood, including make-believe:
25) Interests and hobbies during adolescence:
26) Any athletic interests and/or accomplishments?
27) Present interests, hobbies, activities, organizations:
28) How is most of your free time occupied?
29) Last grade or year completed:______________________________
Degrees:________________________________________________________________
30) Relationship to schoolmates:_____________________________________________
31) Scholastic abilities & disabilities:_________________________________________
32) Were you ever bullied or given a nickname? Please explain:
33) Do you make friends easily? Do you keep them?_____________________________
34) Age when you started working:_______
35) Jobs held in order and reason for changing:__________________________________
36) How long have you been employed at your present job?________________________
37) Does your present work satisfy you? If not, in what ways are you dissatisfied?
38) What do you and your spouse earn?__________________
39) Ambitions and aspirations?______________________________________________
40) Parental attitudes towards sex.. (For example, was there sex instruction or discussion in the home)?
41) When and how did you derive your first knowledge of sex?_____________________
42) When did you first become aware of your sexual impulses?_____________________
43) Did you ever experience any anxieties, guilt feelings or trauma arising out of masturbation? If yes,
please explain.
44) Did you ever experience any anxieties, guilt feelings or trauma arising out of sexual experience with the
opposite sex? If yes, please explain.
45) Did you ever experience any anxieties, guilt feelings or trauma arising out of sexual experience with the
same sex (homosexuality)? If yes, please explain.
46) Menstrual History: Age at first period:___________
46b) Were you informed or did it come as a shock?______________________________
46c) Are you regular?____________ Duration?________________________
46d) Do you have pain?_____ Do your periods affect your moods?_________________
47) Is there any question or concern you have about sex past/present or future, or sexual identity?
48) How long did you know your marriage partner before engagement? ___________
49) How long were you engaged?______ 50) How long have you been married?_______
51) Please describe: What I liked the first few years of marriage.
52) Please describe: What my mate liked the first few years of marriage.
53) Please describe: What I disliked the first few years of marriage.
54) Please describe: What my mate disliked the first few years of marriage.
55) Please describe: What I have liked the last few months of marriage.
56) Please describe: What I have disliked liked the last few months of marriage.
57) Please describe: What my mate has liked/disliked the last few months of marriage.
58) In what areas are you most compatible?
59) In what areas are there incompatibility?
60) How do you get along with your in-laws? (This includes brother and sister in-laws)
61) Give specific examples of those things you would like to see your spouse do more often (e.g.; take the
garbage out, bring you a cup of coffee when you have just sat down to relax, etc.):
62) Give three examples of things you would like to see your spouse stop doing. (Three particular things
that irritate you):
63) Please list the names of your children from oldest to youngest. (State is any of these children are from
a previous marriage or adopted). (Also, in the birth order, please include any miscarriages or abortions).
Please give the following information:
Name Sex Age Marital Status Job Describe each person
PREVIOUS MARRIAGE QUESTIONS:
64) When were you first married and for how long?______________________________
65) How long did you know your first spouse before engagement?__________________
66) How long were you engaged?____________
67) What did you like about your previous spouse?
68) What did you dislike about your previous spouse?
69) What did your previous spouse like about you?
70) What did your previous spouse dislike about you?
71)List all brothers and sisters in order of oldest to youngest including yourself and any miscarriages or
abortions that you know of:
Name Sex Age Marital Status Job Describe each person
72) Describe your relationship with your brothers and sisters in the past.
73) Describe your relationship with your brothers and sisters now.
74) Brother or sister most like you? In what respect?
75) Brother or sister most different from you? In what respect?
76) Who played together?
77) Any unusual achievements?
78) Any accidents or illnesses (bumps to head, hospitalizations)?
79) “Father� here means the man who took primary responsibility for raising you. If this is a
different person from your biological father, please describe what you know of your biological father on
the back of this page and describe your father (as defined above) on this page.
Father’s Name:___________________________ Current Age_____________
Occupation_______________________ Health: Good Average Poor (circle one)
If deceased, cause of death and age at death:___________________________________
Kind of person:
Ambitions for the children:
Relationship to the children:
Relationship with spouse:
Favorite child? Why?
Child most similar to dad, how?
Child most different from dad, how?
As a child, what I liked about dad:
As a child, what I disliked about dad:
80) “Mother� here means the woman who took primary responsibility for raising you. If this is a
different person from your biological mother, please describe what you know of your biological mother on
the back of this page and describe your mother (as defined above) on this page.
Mother’s Name:___________________________ Current Age_____________
Occupation_______________________ Health: Good Average Poor (circle one)
If deceased, cause of death and age at death:___________________________________
Kind of person:
Ambitions for the children:
Relationship to the children:
Relationship with spouse:
Favorite child? Why?
Child most similar to mom, how?
Child most different from mom, how?
As a child, what I liked about mom:
As a child, what I disliked about mom:
81) As a child, in what ways were you punished by your parents?
82) Give an impression of your home atmosphere (the home you grew up in).
83) Were you able to confide in your parents?
84) If you were not brought up by your biological parents, who did raise you? Between what years? If you
were raised by your parents, was there another parental figure?
85) Has anyone (parents, relatives, friends) ever interfered in your marriage, occupation, etc.?
86) Does anyone in your family suffer from alcoholism, drug addiction or anything that can be considered a
mental disorder?
87) Are there any other members of the family about whom information regarding illness, etc. is relevant?
88) Please try to remember any fearful or distressing experiences not previously mentioned.
89) In what kinds of situations do you most readily lose self-control? (Cite particular instances if at all
possible. Examples might be temper, uncontrollable crying, impatience, etc.):
90) In what situations are you best able to maintain self-control?:
91) Give a word picture of yourself as would be described by�
Your spouse:
Your best friend:
Your worst enemy:
Yourself:
Thank you for taking the time to fill out this form. This information will speed the counseling process and
help us focus on issues most relevant to your situation.
You may print this page or copy and paste into your word processor for
printing.