Life History Questionnaire

Life History Questionnaire

The purpose of this questionnaire is to obtain a comprehensive picture of your background. By completing these questions, as fully and as accurately as you can, you will provide your hypnotherapist with important information, without using your actual therapy time. The information in this questionnaire will be kept by your hypnotherapist and will not be disclosed to anyone without your written permission. Case records are strictly confidential. If a question doesn't pertain to you, leave the field blank. If you do not wish to answer a question, simply write: do not care to answer.

Full Name

First NameMiddle NameLast Name

Date

Birth Date

MonthDayYear

Email

If you'd like a copy of your completed questionnaire, please add your email.

Marital Status

If married, how many times?

Please give details of any previous marriage(s).

Please list everyone who presently lives with you.

How many children do you have? Please list their sex and age.

Do any of your children present special problems?

Who are the most important people in your life?

Is your father living or deceased?

If deceased, how old were you at the time of his death?

What was his cause of death?

If alive, what is your father's present age, occupation, and health?

Is your mother living or deceased?

If deceased, how old were you at the time of her death?

What was her cause of death?

If alive, what is your mother's present age, occupation, and health?

How do you get along with your in-laws?

This includes your brothers/sisters in-law

In what areas of the family is there compatibility?

In what areas is there incompatibility?

Give an impression of your childhood home atmosphere.

Mention state of compatibility between parents and between parents and children.

As a child, in what ways were you punished by your parents?

If you were not brought up by your parents, who brought you up, and at what age/years?

Were you able to confide in your parents/caregivers?

If you have a stepparent, what was your age when your parent remarried?

Give a description of your religious affiliations and experiences.

Has anyone ever interfered in your marriage?

What were parental attitudes to sex?

Was there sex instruction or discussion in the home?

When and how old were you when you derived 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?

Select any of the following that apply to you:

What are your current interests, hobbies, and activities?

How is most of your free time occupied?

What is the last grade of school you completed?

What would you consider your scholastic abilities; strengths and weaknesses?

Were you ever bullied or teased?

Do you make friends easily? If so, do you keep them?

What sort of work are you doing now?

What sort of work have you done in the past?

Does your present work satisfy you? If not, in what ways are you dissatisfied?

Please describe your past career ambitions.

Please describe your current career ambitions.

Has anyone ever interfered with your occupation?

Select any of the following that apply to you:

Please list five main fears:

Give a brief account of the history and development of your complaints (from onset to present):

On the scale below, please estimate the severity of your problems.

With whom have you previously consulted about your present problem(s)?

If there is anything you would like to add that was not included above, please feel free to share.