PSYCHOLOGICAL/SOCIAL HISTORY
Name: SS#:DOB: Gender:
DIRECTIONS: Carefully read each question and circle your response.
1. What is your race?
Asian Mexican Caucasian Oriental Latin American
Other American Native Black2. Who primarily raised you?
Natural parents Father only Mother only Father and stepmother
Mother and stepfather Adoptive parents Foster parents Institutional caretakers
Aunt and/or uncle Brother and/or sister Maternal grandparent(s) Paternal grandparent(s)3. How would you characterize your childhood? (circle all that apply)
Happy Dull Painful Frightening Hard to remember Regimented
Unhappy Secure4. Which descriptor(s) characterize your mother (maternal caretaker)? (circle all that apply)
Warm Strict Domineering Distant Rejecting Abusive Uncaring
Over-protective Understanding5. Which descriptor(s) characterize your father (paternal caretaker)? (circle all that apply)
Warm strict Domineering Distant Rejecting Abusive Uncaring Over-protective Understanding6. How would you describe your parents' (or parent substitutes') relationship? (circle all that apply)
Close Indifferent Happy Cold Reserved Loving
Hostile Distant Domineering/submissive7. How many brothers and sisters did you have?
None Three Six One Four Seven
Two Five More than seven8. Which descriptors characterize you as a child (0 to 12 years of age)? (circle all that apply)
Outgoing Shy Active Aggressive Awkward Happy
Friendly Emotional Irresponsible Nervous Rebellious Serious
Stubborn Unhappy Calm Temperamental Self-confident Other9. What was your order of birth?
Oldest Only child Middle Other Youngest10. What were problems for you as a child 0 to 12 years of age)? (circle all that apply)
None Getting along with sibling(s) Bed?wetting Academic
Overweight Getting along with mother Getting along with peers Nightmares
Physical/medical problems Underweight Getting along with father
Getting along with teachers Excessive fears or worries Felt I was a burden to Fear of failure
Burden to my parents11. What did your parents (parental caretakers) argue about'? (circle all that apply)
Discipline of children Sex Not being a good provider Money
Drinking Not taking care of the home Other Relatives interfering
Jealousy Never argued12. What was your father's (paternal caretakers) Occupation?
Service worker Unskilled worker Skilled worker Semiskilled worker
owner/manager owner/high level executive Professional (requires bachelor's degree)
Professional (requires advanced degree) Sales Not in labor force13. What was your mothers (maternal caretakers) occupation?
Service worker Unskilled worker Skilled worker Semiskilled worker
Owner/manager owner/high level executive Professional (requires bachelor's degree)
Professional (requires advanced degree) Sales Not in labor force14. How would you describe Your mother's method of discipline?
Strict inconsistent Fair Lenient15. How would you describe your father's method of discipline?
Strict inconsistent Fair Lenient16. What fears did you have as a child 0 to 12 years of age)? (circle all that apply)
No significant fears Death Strangers Other Might fall
Might become seriously injured/ill Might be abandoned lose my parents Might be laughed at
Animals other children17. How would you characterize your sexual experiences?
Pleasant Neutral Unpleasant18. How far did you go in school?
Completed less than 6 grades Completed elementary school Completed junior high (9h grade)
Attended high school (no diploma) Received a GED. Graduated high school
Vocational/business school training Attended college (did not graduate) Graduated college -four year
Completed graduate level courses Earned a masters degree Earned a doctoral degree19. How would you rate your intellectual ability? (1 answer)
Below average Average Above average Superior/gifted20. Were you ever held back in school?
No Yes21. In general, what grades did you make in school?
Many D's and F's Mostly C's and D's Mostly B's and A's Mostly A's22. Which of the following describe your experiences in high school?
Does not apply None Suspended
Had to be disciplined Expelled Other Frequently23. Did you graduate from high school?
Yes No, dropped out because of No, dropped out to work to support the family
No, dropped out because of poor grades No, dropped out because of drug problems
No, dropped out because of health problems No, dropped out because you got pregnant
No, dropped out because girl- friend got pregnant24. What were your plans when you left high school?
Did not have any plans Planned to get married Join the armed service
Planned to continue education Other25. Did you ever get in trouble while in school?
No Occasionally Often26. Did you have any problems learning to read?
No Yes27. Did you have any problems learning math?
No Yes28. Did your peers ridicule, tease or make fun of you more than other kids?
No Yes29. Rate your family's economic status during childhood and adolescence:
Poverty level (received welfare) Working class Middle class Upper middle class Wealthy30. Who provided the main source of income for your family?
Mother Father A relative Social service agencies Other31. Did your parents agree on how money should be spent?
Agreed most of the time Disagreed Disagreed frequently32. Did your family experience any financial problems?
No Occasionally Often33. Currently, how much money does your household earn?
Less than $8,000 - $15,000 $20,000- $30,000 - $45,000
$8,000 - $12,000 $20,000 - $30,000 More than $45,000
$12,000 - $15,00034. Have you had any major changes in income during the last 2 years?
No Decreased significantly Increased significantly35. What is your family’s primary source of income?
My earnings My partner's earnings Relatives
Disability payments Unemployment Welfare
Investments Other36. Is providing enough income for your family a big stress in your life?
No Yes37. Are you presently employed?
No Yes38. How long have you been working at this job?
Less than 6 months 3 to 10 years More than 20 years
6 months to 1 year 10 to 15 years Does not apply
1 to 3 years 15 to 20 years39. How many hours per week do you work?
Less than 10 20 to 30 More than 45
10 to 20 30 to 45 Does not apply40. In general, how do you enjoy your work?
Enjoyable Neutral Unenjoyable Does not apply41. Have you ever been fired?
No Yes Number of times42. Have you ever been laid off?
No Yes Number of times43. What is the longest period of time you held one job?
Less than 1 year 3 to 5 years More than 10 years
1 to 3 years 5 to 10 years44 Since starting full?time work, what is your longest unemployed period?
Less than 1 year 3 to 5 years More than 10 years45. Do you have any problems at work?
No Yes46. What kinds of work have you performed in the past? (circle all that apply)
Service worker Owner/manager Sales Unskilled worker
Owner/high level executive Not in labor force Skilled worker Professional (requires bachelor's degree)
Semiskilled worker Professional (requires advanced degree)47. Have you ever served in the military?
No Yes48. Which branch did you serve in?
Air Force Army Navy Marines Coast Guard Does not apply49. How long did you serve?
Less than 3 months 3 to 5 years More than 15 years
Less than 1 year 6 to 10 years Does not apply
1 to 2 years 10 to 15 years50. What kinds of problems did you experience while in the military?
Getting used to rules & regs Began using drugs Had to do special duty(conduct) Other Went AWOL Taking orders Began using alcohol to excess
Did time in the stockade/brig51. Were you stationed in a combat zone?
No Yes, for less than 3 months Yes, for 3 to 6 months Yes, for 6 months to 1 year
Yes, for 1 to 2 years Yes, for 3 to 4 years Yes, for longer than 4 years Does not apply52. What was the highest rank you attained?
Enlisted person Noncommissioned officer Officer Does not apply53. What were the terms of your discharge?
Nerves Was reprimanded for my conduct Was court?martialed None or does not apply
Still on active duty Honorably discharged (mental problem) Dishonorably discharged
Honorable discharge Honorably discharged (physical problem) Does not apply54. Did you ever see a psychologist or psychiatrist while in the military?
No Was hospitalized for mental problems Does not apply
For evaluation only For evaluation & treatment (Out Patient)55. Do you have a service?connected disability?
No Physical Mental
Physical and mental Does not apply
56. Which of the following have you used? (circle all that apply)
None Cocaine Barbiturates Amphetamines
Hallucinogenic Opium Quaaludes Heroin Marijuana
Tranquilizers without prescription PCP Pain pills without prescription57. Have you ever felt there was a time you drank too much alcohol?
No Yes, on one occasion Yes, on more than several occasions
Yes, on several occasions58. On the average, how often do you drink alcohol?
Never Once or twice a year Once a month
Once a week Several times a week Daily59. Which of the following have you experienced? (circle all that apply)
None Lost a job due to drinking Missed work due to drinking
Were in fights because of drinking Were arrested for being drunk and disorderly
Had an automobile accident because of drinking Received a ticket for drinking and driving
Lost driver's license because of drinking Had arguments with friends or relatives because of drinking60. Have you ever been involved in an alcoholism or drug treatment program?
No Yes61. Did your parents have a problem with alcohol when you were a child?
No Mother only Father only B oth parents did The person who raised me did62. Do you use any illegal drugs?
No Occasionally Daily No, but did in the past Regularly63. Which drugs do you, or did you, abuse? (circle all that apply)
Does not apply Narcotics Recreational Prescription Other64. How long have you been using, or did you use, illegal drugs?
Does not apply Two years Five years Less than one year
Three years Over five years One year Four years65. Which of the following have you been treated for as an adult? (circle all that apply)
None Arthritis Cancer Diabetes Epilepsy (seizures) Heart problems
Hypertension Low back pain Problems with lungs or breathing Problems with digestive system Other66. What are you currently being treated for? (circle all that apply)
Not being treated Arthritis Cancer Diabetes Epilepsy (seizures) Heart problems
Hypertension Low back pain Problems with lungs or breathing Problems with digestive system Other67. Do you currently have any physical problems that are not being treated by a medical doctor, but should be? (circle all that apply)
No Chest pain Difficulty with breathing Dizziness Loss of consciousness Pain
Stomach problems Vision problems Other68. How many cigarettes a day do you smoke?
None, have never smoked None, but used to smoke Less than one pack per day
One pack per day More than one pack per day69. How long have you been smoking (or did you smoke) cigarettes?
Have never smoked 5 to 10 years More than 15 years
Less than five years More than 10 years More than 20 years70. Have any family members ever experienced mental illness?
No I have Mother Father Sibling(s) (brother(sister(s)} Grandparent71. Did you have any bad illnesses as a child? (e.g. hospitalizations)
No Yes72. Have you had any significant accidents in the past 3 years? Head injuries?
No Yes73. Have you had any major illnesses or hospitalizations in the past 3 years?
No Yes74. Rate your general level of health:
Excellent Good Fair Poor Extremely poor75. Are you currently under the care of a physician?
No Yes76. What medications are you currently taking? (circle all that apply)
None Pain pills Antibiotics
Anti-inflammatory pills Anticonvulsant pills Heart pills
High blood pressure pills Tranquilizers Antidepressants
Vitamins Insulin Allergy pills
Stomach pills Other77. Has there been a recent change in your weight?
No Yes, a weight gain Yes, a weight loss Yes, a weight loss due to dieting78. Has there been a recent change in your appetite?
No Yes, an increase in appetite Yes, a lost appetite79. What problems do you have with your sleep?
None Trouble getting to sleep Wake up a lot at night Don't get enough sleep
Sleep too much Restlessness Wake up too early in the morning
Sleep enough, but don't feel rested Nightmares Other80. Do you eat a balanced diet?
No Yes81. Do you participate in a regular exercise program?
No Yes82. How would you characterize your size? (I answer)
Very thin Thin About average A little overweight Overweight
Very overweight83. What is your marital status?
Never married First marriage Re-married
Divorced Widowed Cohabiting Separated84. Have you ever been divorced?
No Yes How many times?85. How long have you been with your current partner?
Does not apply Less than 1 year Number of years
86. How many children do you have?
None 3 6 1 4 7 2 5 More than 787. How would you describe your partner? (circle all that apply)
Warm Unhappy Distant Uncaring Happy Frustrating
Enjoyable Abusive Faultfinding Understanding Unforgiving
Tense Argumentative Boring Affectionate Does not apply88. Are you having problems with your child(ren)'s behavior?
No Yes Does not apply89. Check all the problems which trouble you.
Being uncomfortable with opposite sex Being afraid of sexual diseases
Having a sexual disease Being gay Worrying about sexual performance
Having unsatisfactory sexual relationship Thinking about sex too often
Disliking sex Being troubled by unusual sexual behavior Other90. Is the frequency of sex a problem for you?
No Yes91. Is the frequency of sex a problem for your partner?
No Yes92. Which is true about your sex life?
Prefer not to answer I am interested in sex, but not active at this time
Have an active sex life Have an active sex life Have no interest in sex93. Has there been a recent change in your interest in sex?
Prefer not to answer Yes, a decrease in interest No
94. What are your living arrangements?
Living with relatives in their home Living with friends in their home Renting a home/apartment Living in a dorm Own my home Boarder95. How often do you and your partner argue?
Never Once a week Several times a day Rarely
Several times a week Does not apply once a month Daily96. Has your relationship ever been threatened by an affair?
No Does not apply Yes, my affair Yes, my partner's affair97. Which of the following have you experienced in the last 5 years? (Circle all that apply)
Not having any religious beliefs Not having good philosophy of life Not being able to get to church
Work interfering with religious practices Being rejected by church Being confused about religious beliefs Failing in religious beliefs Feeling abandoned by God Worrying about being accepted by God98. What is your religious affiliation?
None Jewish Atheist Protestant Muslim Agnostic Catholic Buddhist Other99. Are any of the following problems occurring or about to occur? (Circle all that apply)
Needing legal advice Being someone's guardian Not receiving child support having legal problem with neighbors None Being sued Being on parole Not receiving alimony Not having retirement funds Being legally disowned by family Facing criminal charges No Legal problems100. Which of the following have you experienced in the past year? (Circle all that apply)
None Marriage spouse or partner being seriously ill or injured
Death of spouse or partner Child being seriously ill or injured Parent being seriously ill or injured Other Separation Birth of child financial problems Serious illness or injury Spouse or partner losing job Spouse or partner changing jobs Divorce Death of child Death of a parent Change of jobs Loss of job101. How would you rate your ability to cope with life?
Very good Good Average102. How would you describe yourself? (Circle all that apply)
Quiet Unassertive Shy Active Aggressive Temperamental
Self-confident Carefree Stubborn
Friendly Smart Impatient Happy
Responsible Rebellious Serious Depressed Worried Unenthusiastic Regretful Scared103. How would you describe your mental state? (Circle all that apply)
Tense Sad Angry Disappointed Calm Nervous
Forgetful Fearful Confused Irritable Hyperactive Distrustful104. Have you ever had legal problems?
No Civil (e.g. divorce) Criminal105. What is the primary problem bothering you? (1 answer)
Marriage Family Loneliness Moodiness Depression Anxiety
Self-confidence Physical (ill/tired) Alcohol Drugs Sex Memory
Work Other106. How long ago did you begin to be troubled by this problem? (1 answer)
Within the past month Between 1 and 2 years Over 10 years
Between 1 and 6 months Between 2 and 5 years All my life
Between 6 and 12 months Between 5 and 10 years Does not apply107. Rate the degree to which this problem has affected your life. (1 answer)
Very little A good deal A little A great deal108. How often do you experience this problem? (1 answer)
Many times a day Several times a week Monthly Several times a day
Once a week Several times a year A fair amount
Does not apply Daily Several times a month Less than once a year109. What other kinds of problems are bothering you? (Circle all that apply)
Marriage Moodiness Self?confidence Drugs
Work Family Depression Physical (ill/tired)
Sex Other Loneliness Anxiety
Alcohol Memory Does not apply
AAI questions
1. Could you start by orienting me to your early family situation, where you lived, and so on? If you could start with where you were born, whether you moved around much, what your family did for a living at various times.
2. I'd like you to try to describe your relationships with your parents as a young child. If you could start from as far back as you can remember.
3. To which parent did you feel closest and why? Why isn't there this feeling with the other parent?4. When you were upset as a child, what would you do?
5. What is the first time you remember being separated from your parents? How did you and they respond? Are there any other separations that stand out in your mind?
6. Did you ever feel rejected as a young child? Of course, looking back on it now, you may realize that is wasn't really rejection, but what I'm trying to ask about here is whether you remember ever having felt rejected in childhood.
7. Were your parents ever threatening with you in any way - maybe for discipline, or maybe just jokingly?
8. How do you think these experiences with your parents have affected your adult personality? Are there any aspects of your early experiences that you feel were a set-back in your development?
9. Why do you think your parents behaved as they did during your childhood?
10. Were there any other adults with whom you were close as a child, or any other adults who were especially important to you?
11. Did you experience the loss of a parent or other close loved one while you were a young child?
12. Have there been many changes in your relationship with your parents since childhood? I mean from childhood through until the present?
13. What is your relationship with your parents like for you now as an adult?
14. Is there any particular thing which you feel you learned above all from your own childhood experiences?
15. What would you hope your child might learn from his/her experiences of being parented?