Some problems are unusually complex and it can help both yourself and your doctors understand things better if you take time to sit down and reflect on the situation using this questionnaire as a guide. You should really make an effort with this and generally it is the first answer that comes to your mind which is the right one! Occasionally there may be an answer you may not wish to write down and which you would prefer to discuss with your physician; just indicate such a deferment on the questionnaire.
In Depth Questionnaire
Name: Today’s Date:
Date of Birth:
Contact number:
Tell me about your problem (s):
When and how did it (they) start?
What was happening in your life when it (they) started?
What are your current symptoms?
Who else has a problem like yours?
What do your symptoms prevent you from doing?
What would you do differently if your problem were cured?
How would you cope with this problem if there were no cure?
What is the most frightened you have ever been?
What is the most angry you have ever been?
What event hurt your feeling the most?
What is the worst thing that ever happened to you?
What is the worst thing you ever did?
Who are your heroes/heroines?
Who do you most hate/despise?
What makes life worth getting up for?
What is the best job you could have had?
What is the worst job you could have possibly had?
Childhood and Family History:
Marital/ significant Partner History:
Current Family Profile:
Occupation, qualifications and Hobbies:
What are your dreams for the future?
Is there anything else I should know?
Bernard Shevlin b.shevlin02@gmail.com