Have you ever had a severe emotional upset before? Yes___ No __ Explain______________________________________________________
Have you ever had any psychotherapy or counseling before? Yes ___ No ___
If yes, list counselor or therapist and dates: _____________________________________________________________________
What was the outcome? _____________________________________________________________________
Circle any of the following words that best describe you now:
| active ambitious self-confident persistent nervous hardworking
impatient impulsive moody often-blue excitable imaginative calm
easy-going shy good-natured introvert extravert likeable leader quiet
hard-boiled submissive self-conscious serious lonely sensitive other __________________________________________________ |
Have you ever felt people were watching you? Yes ___ No ___
Do people's faces ever seem distorted? Yes ___ No ___
Do you ever have difficulty distinguishing faces? Yes ___ No ___
Do colors ever seem too bright? ________ Too Dull? _______
Are you sometimes unable to judge distance? Yes ___ No____
Have you ever had hallucinations? Yes ___ No ___
Is your hearing good? Yes ___ No ___
Do you have problems sleeping? Yes ___ No ___
How many hours of sleep do you average each night? __________
BRIEFLY ANSWER THE FOLLOWING QUESTIONS:
Please describe what brings you here.________________________________________________________________________
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