Adult Questionnaire

Psychotherapy Client Questionnaire
Confidentiality Statement:

Case records are strictly confidential. No outsider, not even your closest relative or family doctor is permitted to see your case record without your written permission or court order.
Name*

First NameLast Name
Today’s Date*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Date of birth:*

MonthDayYear
Date
Place of Birth:*
What is your current living situation?*
Do you have children?*

YesNo
If so, list their names and ages:
Give a short history of your closest interpersonal relationships:*
Education:*
Occupation:*
Are you currently employed?*

YesNo
What is your present job situation?

	A little of the time	Some of the time	A good part of the time	Most of the time
I feel more nervous and anxious than usual
I feel afraid for no reason at all
I get upset easily or feel panicky
I feel like I’m falling apart and going to pieces
I feel that everything is alright and nothing bad will happen
My arms and legs shake and tremble
I am bothered by headaches, neck and back pain
I feel weak and get tired easily
I feel calm and can sit still easily
I can feel my heart beating fast
I am bothered by stomach aches or indigestion
I have to empty my bladder often
My hands are usually dry and warm
My face gets hot and blushes
I fall asleep easily and get a good night’s rest
I have nightmares
I am bothered by dizzy spells
I have fainting spells or feel like it
I can breathe in and out easily
I get feelings of numbness and tingling in my fingers and toes

	Not at all	Mildly - it didn’t bother me much	Moderately - it wasn’t pleasant at times	Severely - it bothered me a lot
Numbness or tingling
Feeling hot
Wobbliness in legs
Unable to relax
Fear of the worst happening
Dizzy or lightheaded
Heart pounding/racing
Unsteady
Terrified or afraid
Nervous
Feeling of choking
Hands trembling
Fear of losing control
Difficulty breathing
Fear of dying
Scared
Indigestion
Faint/lightheaded
Face flushed
Hot/cold sweats

Psychotherapy Client Questionnaire