FAMILY HISTORY QUESTIONNAIRE
HOME | PANIC DISORDER | OBSESSIVE-COMPULSIVE DISORDER | SOCIAL PHOBIA | POSTTRAUMATIC STRESS DISORDER | GENERALIZED ANXIETY DISORDER | SELF-TEST | COGNITIVE-BEHAVIORAL THERAPY | LIGHT THERAPY | RECOMMENDED READING | FOR NEW PATIENTS | "ANXIETY TO SERENITY" CD series/PURCHASE TELEPHONE SESSIONS

 
 
Please print and complete the following questionnaire to help identify early life conditions that may contribute to your current anxiety.
 
 
1.  Were either of your parents a "worrier" or experience anxiety or panic attacks?  Describe:
 
__________________________________________________________
 
__________________________________________________________
 
2. Do you have a brother, sister or other relative with anxiety? Describe:
 
__________________________________________________________
 
__________________________________________________________
 
3.  Were either of your parents overly concerned about potential dangers that could befall you or others? Describe:
 
__________________________________________________________
 
__________________________________________________________
 
4.  Did your parents seem to encourage exploration of the outside world or did they create an attitude of caution and distrust of the world? Describe:
 
__________________________________________________________
 
__________________________________________________________
 
5.  Were either of your parents overly critical or demanding of you? If so, how did that make you feel? Describe:
 
__________________________________________________________
 
__________________________________________________________
 
6.  Did you experience or witness emotional, verbal or physical abuse from either parent? Describe:
 
__________________________________________________________
 
__________________________________________________________
 
7.  Did you feel frightened or intimidated by either parent? Describe:
 
__________________________________________________________
 
__________________________________________________________
 
8. Did either of your parents make you feel ashamed, guilty, neglected or abandoned?  Describe:
 
__________________________________________________________
 
__________________________________________________________
 
9.  Were either of your parents alcoholic or a heavy drinker?  Describe:
 
__________________________________________________________
 
__________________________________________________________
 
10. Do any of the following describe your current relationship with your parent(s)?
     __  Dependent on them (daily or very frequent contact, difficulty leaving  home, living very close to them)
     __ Very independent (infrequent contact, leaving home early in life, moving very far away)
     __  Hostile or alienated
 

Go to:

First Panic Questionnaire

 
Return to:

For New Patients

Enter content here

Enter content here

Enter content here