Online Questionnaire
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Resume Code:
Dan McGann Therapy Inc.
Questionnaire: Individual and Family History
Please complete the full form as best as you can. All questions are optional answer.
* Email is required to send you a copy with the Resume Code if you wish to update the questionnaire at a later time.
Email *
Date
Address
Name
Telephone Number (Day)
Telephone Number (Evening)
Date of Birth
Age
Occupation
Place of Birth
Immigrated?
Immigration Status
By whom were you referred?
Where do you reside?
With whom do you reside?
Significant relationship status?
Years in relationship?
Partner's name?
Partner's age?
Partner's occupation?
Brief details of previous relationships:
Any children?
How many?
Any significant problems with any of these children?
List children's name, age, gender:
Any history of abuse (emotional, physical, sexual) in current of previous relationships?
Role of religion and/or spirituality in childhood:
Role of religion and/or spirituality as an adult:
Clinical
State in your words the nature of you main problems and how long they have been present:
Give a brief history and development of your complaints (from onset to present):
Please check the severity of your problem(s)
Whom have you previously consulted about your present problem(s)?
Are you taking any medications? If "yes", what, how much, and with what results?
Personal Data
Health during childhood? List illnesses:
Health during adolescence? List illnesses:
Your weight?
Any drastic changes with your weight?
Any surgical operations? (please list them and give the age at the time:
Any accidents?
Check any of the following that apply to you:
Headaches
Palpitations
Bowel Disturbances
Anger
Nightmares
Feel tense
Depressed
Unable to relax
Don't like weekends or vacations
Can't make friends
Can't keep a job
Financial problems
Excessive sweating
Dizziness
Stomach trouble
Fatigue
Take sedatives
Feel panicky
Conflict
Suicidal ideas
Sexual problems
Overambitious
Inferiority feelings
Memory problems
Lonely
Use aspirin or painkillers often
Fainting spells
Anxiety
No appetite
Feel cold a lot
Insomnia
Alcoholism
Tremors
Take drugs
Allergies
Shy with people
Can't make decisions
Home conditions bad
Unable to have a good time
Concentration difficulties
Is there a family history of mental illness? If so please indicate who and what their illness was:
Any family history of drug and/or alcohol use? Who?
List your five main fears
Present interests, hobbies and activities
How is most of your free time occupied?
Do you belong to any clubs organizations?
Were you ever bullied or severely teased?
Do you make friends easily?
Do you keep your friends?
Educational history
What is the last grade of school that you completed?
Scholastic abilities: strengths and weaknesses?
Describe your school experiences:
Were there any problems with truancy, suspensions, special education, vocational training, etc?
Occupational Data
What sort of work are you doing now?
List previous jobs:
Does your present work satisfy you? (If not, in what ways are you dissatisfied?)
Do you experience worry or stress over your finances?
Ambitions/Goals: Past
Ambitions/Goals: Present
If on a leave of absence or disability, will you return to your present job?
Marital History
How long did you know your marriage partner before engagement?
How long have you been married?
How long have you been in a common-law relationship?
Describe the personality of your partner (in your own words):
In what areas is there compatibility?
In what areas is there incompatibility?
How do you get along with your in-laws? (This includes brothers and sisters-in-law)
Any history of miscarriages or abortions?
Family Data
Is your father still alive?
If deceased, your age at the time of his death?
If deceased, cause of his death?
If alive, father's present age, occupation and health?
Is your mother still alive?
If deceased, your age at the time of her death?
If deceased, cause of her death?
If alive, mother's present age, occupation and health?
Number of brothers
Brothers ages
Number of sisters
Sisters ages
Relationship(s) with brothers and sisters: Past
Relationship(s) with brothers and sisters: Present
Give a description of your father's personality and his attitude toward you (past and present)
Give a description of your mother's personality and her attitude toward you (past and present)
In what ways were you punished by your parents as a child?
Give impressions of your home atmosphere
(i.e. the home in which you grew up, including compatibility between parents and between parents and children):
Were you able to confide in your parents?
Did your parents understand you?
Basically, did you feel loved and respected by your parents?
If you have a step-parent, give your age when your parent remarried:
Describe your religious training:
If you were not raised by your parents, who did raise you, and between what years?
Has anyone (parents, relative, friends) ever interfered in your marriage, occupation etc.?
Who are the most important people in your life?
Does any member of your family suffer from alcoholism, epilepsy, or anything which can be considered a "mental disorder"?
Are there any other members of the family about whom information regarding illness, etc., is relevant?
Recount any fearful or distressing experiences not previously mentioned?
General
What do you expect to accomplish from therapy, and how long do you expect therapy to last?
List any situations which make you feel calm or relaxed
Have you ever lost control (e.g. temper or crying or aggression)? If so, please describe.
Please add any information that may aid me in understanding and helping you
168 Queen St South, Suite 204
Mississauga, ON., L5M 1K8
Phone: 416 970 2396
(Just above the TD Canada Trust in Streetsville)

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