Personal History
Education:
School years?
Trusting?
Friends?
Bullying?
Qualifications?
Childhood:
Where born?
Any complications in birth?
Developmental stages?
Home atmosphere?
Relationship with parents?
Employment:
Current jobs?
Previous jobs?
How many?
Reasons for leaving?
Spiritual beliefs:
Brought up with religion?
Currently practice?
Sexual history:
Any difficulties during puberty?
Any distressing sexual experiences?
Sexually active?
Any problems?
Relationships:
Family dynamics
Past serious relationships
Social network
Plans?
Substance Use (identify if the following are used as coping mechanisms for the issue in question)
Alcohol: What sort? How much? What strength? What time of day? Why do you use it? Does it help with your symptoms? Any intention to reduce or stop?
Illegal Drugs: What sort? How much? What strength? What time of day? Why do you use it? Does it help with your symptoms? Any intention to reduce or stop?
Prescribed Medication: What sort? How much? What strength? What time of day? Why do you use it? Does it help with your symptoms? Any intention to reduce or stop?
Non-prescribed Medication: What sort? How much? What strength? What time of day? Why do you use it? Does it help with your symptoms? Any intention to reduce or stop?
Tobacco: How much? What strength? What time of day? Why do you use it? Does it help with your symptoms? Any intention to reduce or stop?
Caffeine: How much? What time of day? Why do you use it? Does it help with your symptoms? Any intention to
reduce or stop?
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