PSYCHOLOGICAL EVALUTAION QUESTIONNAIRE

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PSYCHOLOGICAL EVALUTAION QUESTIONNAIRE The purpose of this questionnaire is to obtain an understanding of your life experience and background which is part of the evaluation process. Please bring this fully completed to your scheduled appointment. Name: Date: DOB: Age: Place of Birth: Relationship status (check one) _single _ married _divorced committed relationship Who referred you? Reason: Donor Recipient Surrogate Family of Origin & Personal Information _Happy childhood-explain. _Unhappy childhood- Explain. Health during childhood/adolescence? Any hospitalizations? (List illnesses) Father: Living or deceased? _ If alive, father s present age? _ Occupation? Health? Mother: Living or deceased? _ If alive, mother s present age? Occupation? Health? Siblings: Number of brothers: Brother s ages: Number of sisters: Sister s ages: Relationship with brothers and sisters> Give a description of your father s personality and his attitude toward you: Give a description of your mother s personality and her attitude toward you: In what ways were you punished by your parents as a child? Were you ever bullied or severely teased? If yes, about what? Basically, did you feel loved and respected by your parents? Did your parents ever divorce and if so what age were you?

If you have a step parent, were there any step siblings and please give their genders and ages? Please share education including highest degree obtained and if what field. Do any members of your family suffer from alcoholism, substance abuse or anything which can be considered a mental disorder such as depression or anxiety? _ Do any members of your family have any major medical problems such as heart, cancer or diabetes, etc.? What is your religion and/or spirituality? In childhood and presently: Are you or were you ever in the military? Explain: Have you ever been arrested? If yes, when and what for. Are you currently on probation? Yes / No Explain. _ Have you traveled out of the country and if so where? _ Occupation & Employer: Does your present work satisfy you? (If not, in what ways are you dissatisfied?) Ambitions/Goals: Do you have any financial concerns, present or upcoming? _ What are your current life stressors? Clinical Information: What do you do to manage your stress? _ Present interests, hobbies or activities:

Who are the most important people in your life? Have you had any previous mental health therapy or psychiatric hospitalization(s)? Please explain. Underline any of the following that apply to you: headaches dizziness fainting spells palpitations stomach trouble anxiety easily agitated decreased energy no/more appetite anger always tired insomnia nightmares feel panicky lonely feel tense helplessness tremors/shaking depressed suicidal ideas feel guilty unable to relax sexual problems racing thoughts overly ambitious shy w/ people can t make friends inferiority feelings decisions tough can t keep a job memory problems perfectionistic excessive sweating poor concentration procrastinator Circle any of the following words which apply to you: Worthless, useless, a nobody, life is empty Inadequate, stupid, incompetent, naive, can t do anything right Evil, morally wrong, horrible thoughts, hostile, full of hate Anxious, agitated, cowardly, unassertive, panicky, aggressive Ugly, deformed, unattractive, repulsive Depressed, lonely, unloved, misunderstood, bored, restless Confused, unconfident, in conflict, full of regrets Worthless, sympathetic, intelligent, attractive, confident, considerate Have you ever experienced any emotional/physical/neglect either as a child or adult? Explain. Have you in the past or are you presently having any suicidal ideations/ attempts? Please explain. Do you drink alcohol? If yes, how often and how much? Have you ever used illegal drugs? If so, what drug(s). Include prescription drugs if used other than prescribed. Do you drink caffeine (coffee, tea, soda) and if so how much daily? Do you smoke cigarettes and if so how much daily? Please list any medications you are taking and for what condition?

Please explain any current medical problems you are having? Do you have any tattoos, piercings or had any blood transfusions? If so, explain. _ Sexual History: Did you have a positive first sexual experience? If not, please explain. Have you ever been sexually abused or raped? If so, please explain. How many sexual partners have you had? Have you ever had a sexually transmitted disease? If yes, please identify. Please provide a brief history of miscarriage, abortions or infertility. Relationship / Marital History: Are you currently in a relationship and for how long? If married or in a relationship, partner s name, age, occupation? How are you getting along with your partner/spouse? Describe the personality of your current spouse/partner. How many times have you been married and for how long? Do you have any children/stepchildren? _ No If so, please list their gender and age(s) With whom are you now living? (list people and relation to you)

Self-Description (Answer with first thoughts): A. The most important thing that happened in my life was B. All my life I wanted C. Ever since I was a child, I D. One of the things I feel proud of is E. It s hard for me to admit F. One of the things I can t forgive is G. One of the things I feel guilty about is H. If I didn t have to worry about my image I. One of the ways people hurt me is J. Mother was always K. What I needed from mother and didn t get was L. Father was always M. What I wanted from father and didn t get was N. One of the things I m angry about is O. The worst thing that has happened in my life is P. Which three words best describe you? Signature: Date:

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