Jesus Christ paid for your freedom; He came to destroy the works of the Devil 1Jn 3:8.

When going through this list, please pray that the Holy Spirit will reveal the truth. God resists the proud, but gives grace unto the humble. Please be honest, you have our full confidentiality, but light needs to expose ALL darkness. If you keep even a little bit to yourself, full freedom is not possible. Joshua 7 Achan kept to himself a few accursed objects and caused Israel to be defeated and 36 men died. This work is 2/3 of the process; casting out demons is the easy part!
The purpose of this form is to help determine possible entry ways for evil spirits...obviously, generational/ancestral permission as forewarned in Exodus 20:5 is a possibility in anyone's life. There are ancestors in your history that could have passed a spirit on to you, likely, you only know about your parents and each of their two parents. 1. Please give any information that the Holy Spirit brings to your mind. Examples would be involvement with the occult, sexual perversion, alcoholism, depression or mental disorders, lots of divorce, adultery, anger, criminal activity, births out of wedlock, involvement in groups such as Free-Masonry, Shriners, Eastern Star, Odd Fellows, Rainbow Girls, and Rebecca Lodge etc. Aware of ancestor involvement in any of these?: If Yes, explain: Yes No

Note: It is not necessary to go into detail with any of your responses. Ask the Holy Spirit to show you any area of concern. 2. From birth and your early childhood: Trauma during pregnancy by your mom or dad, divorce, words of "We shouldn't be having this child", spent time in incubator, etc.? If Yes, explain:

3. Early childhood fears, injuries, nightmares, see things in your room, felt evil presence, supernatural attacks? If Yes, explain:

4. Any sexual abuse or sexual embarrassment? If Yes, explain:

5. Spoken words from parents, or others that were condemnation: "You're fat,

you're stupid, you'll never amount to anything, you always mess up, I don't know why we had you. You can't be in our group, etc embarrassing or humiliating experiences at school or from school teacher? If Yes, explain:

6. Any physical abuse from parents or others? If Yes, explain:

7. Involvement (however innocently it may have been) with Ouija Boards, Magic 8 Ball, levitation games, sances, fortune tellers, tarot cards, astrology, horoscopes, fascination with books about magic, psychic seers, Harry Potter books, Pokmon cards, Role playing games that involve magic, etc.?: If Yes, explain:

8. Please list accidents or injuries that come to your mind as being frightening to you at the time:

9. Please list surgeries and approximate age:

10. Movies or TV programs that were particularly frightening to you, or specific scenes that seem to stick in your memory:

11. Have you participated in pre-marital sex?: Periods of immorality? If Yes, explain and specify ages:

Yes

No

12. Drinking and/or drug use? Any supernatural experiences while high? If Yes, explain and specify ages:

13. What do you fear? Or what triggers fear (lie, circumstance)? Please list all:

14. What do you think may be the areas of demonic influence in your life?

15. Problems in home? If Yes, explain:

16. Are your parents divorced?: If Yes, how old were you?

Yes

No

17. Unusual feelings such as: Never really felt loved, couldn't please my father/mother, feelings of worthlessness, etc.? If Yes, explain:

18. Exposed to pornography?: If Yes, how old were you?

Yes

No

Please answer the following questions as they apply to your life: 19. Homosexual tendencies? 20. Participated in college fraternities or sororities? 21. Feelings of guilt and shame? 22. Hopelessness? 23. Fatigue without medical reason? 24. Abortion or caused girl to get one? 25. Difficulty in forgiving, to include yourself or God? 26. Is there bitterness, anger, or unforgiveness? 27. If so, can you forgive? 28. Do you hate yourself? 29. Have you suffered from self harm? 30. Do you have feelings of gloom? 31. Do you feel rejected? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No No

32. Do you have any objects in your home or possession that relate to ungodliness or cults, this would include new age religions, such as books about eastern deities, crystals, heavy metal music, Mother Mary (or any idol) Native American artifacts, wiccan, etc.? Also, frogs, owls, dragons, snakes, and scorpions are demons in the Bible: Yes If Yes, can you give examples? No

33. Ever "felt" a presence in the room? If Yes, has it been recently? If either question was Yes, please explain:

Yes Yes

No No

34. Do you have nightmares? If Yes, do you hear voices? If either question was Yes, please give an example:

Yes Yes

No No

35. Have you been diagnosed by a doctor as having: (list any diagnosis, diabetes, asthma hypertension, etc.)? If Yes, list the diagnosis here:

Yes

No

36. Do you have inexplicable pain...no medical explanation for it? If Yes, please explain: 37. Do you have difficulty in trusting others? If Yes, do you know why? Please explain:

Yes

No

Yes

No

38. Has there been a death of someone close to you? If so, whom?

Yes

No

After the death, did problems or addictions in your life get worse? 39. Do you feel like you have any eating disorders? If Yes, do you know when they began? Yes No

40. Do you suffer from sleep disorders? 41. Any other medically defined disorder? If Yes, please explain:

Yes Yes

No No

42. Is there a history of tuberculosis, diabetes, ulcers, cancer, heart disease, glandular problems, asthma, other, in your family? Yes If Yes, please explain: No

43. Did you have an imaginary friend(s) as a child? If Yes, what were their names? 44. When attending Church/other ministries do you have "foul" thoughts, jealousies or other mental harassment? 45. Do you have difficulty retaining God's Word? 46. Difficulty in reading it? 47. Do you have migraine headaches? 48. Do you have any addictions or compulsions? What are they? 49. Were you ever diagnosed with a learning disability i.e. (A.D.D.), etc? 50. Do you have a fear of death? 51. Have suicidal thoughts? 52. Has there been a period of time in your life when you were angry with God? 53. Do you fear of losing your mind? 54. Anxiety or panic attacks? If Yes, when did they begin? Have you been in combat or to a war zone? 55. Do you feel incredible loneliness? 56. Are you plagued with doubt and unbelief? 57. Do you feel inferior? 58. Do you hate silence; always have the TV/Radio on? 59. Do you have obsessive thoughts?

Yes

No

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No No No No

Yes Yes Yes Yes Yes

No No No No No

60. Blasphemous thoughts? 61. Compulsive thoughts? 62. Lustful thoughts? 63. Are you prideful? If so, are you able to be fully honest in this questionnaire? 64. Are you a perfectionist? 65. Are you isolated, no one understands? 66. Do you feel the need to be in control, things are always out of order? 67. Are you rebellious? 68. Insecurity? (Scale of 1-10 with 10 being worst)? Please explain:

Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No

69. Here are a few more overt symptoms of demonic attack. This list is not comprehensive; it is very rare for a Christian to not have any demons before deliverance. Please check any symptom that applies to you:
1. 2. 3. 4. 5. 6. 7. 8.

A compulsive desire to blaspheme God. A revulsion against the Bible, including a desire to tear it up or destroy it. Compulsive thoughts of suicide or murder. Deep feelings of bitterness and hatred toward others without reason: Jews, other races, the church, strong Christian leaders. Any compulsive temptations or emotions which master you. Compulsive desires to tear other people down, even if it means lying to do so. Vicious cutting by the tongue, or you feel like you are helping but your tongue only hurts. Terrifying feelings of guilt/shame even after honest confession is made to the Lord. Certain physical symptoms which may appear suddenly or leave quickly and there are no physical or physiological reason.
A. B. C. D.

Choking sensations. Pains which seem to move around and for which there is no medical cause. Feelings of tightness about the head or eyes. Dizziness, blackouts, or fainting seizures.

9. 10.

Deep depression and despondency. Sudden surges of violent rage, uncontrollable anger, or seething feelings of hostility.

11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40.

Terrifying doubt of one's salvation even though they once knew the joy of salvation. Panic attacks or other fears that are terrifying. Dreams or nightmares that are of a horrific nature and often ...recurring. Clairvoyant dreams that may even come true are most often demonic. Abnormal or perverted sexual desires, to include homosexuality. Questions and challenges to God's Word. Sleep or eating disorders without physical cause. Most compulsions, obsessions and addictions. Rebellion and hatred for authority. Bizarre terrifying thoughts that come from nowhere and you cannot control them. Fascination with the occult, (to include movies, video games, research, etc). Involvement in criminal activity. Extremely low self-image, self-hatred, cutting (unworthy, a failure, no good). Constant confusion in thinking (sometimes great difficulty in remembering things). Inability to believe (even when the person wants to). Mocking and blasphemous thoughts against preaching/teaching of the Word of God. Perceptual distortions - perceiving anger, hostility, in others when it doesn't really exist - seeing only judgment in the scriptures. Even after confession, dont feel holy or forgiven until days after. Need punishment. Violent thoughts (suicidal, homicidal, encouraging self-abuse, etc.). Hatred and bitterness toward others for no justifiable reason. Tremendous hostility or fear when encountering deliverance workers. Feelings of being watched or sensing an evil presence. Diagnosed with Post Traumatic Stress Disorder or PTSD Irrational fears - panic attacks - phobias. Animals fear you for no reason. Marks, symbols or scratches appear on your body for no reason. Desire to do what is right (inability to carry it out despite true repentance). Sudden personality and attitude changes (severe contrasts - appears schizophrenic) Bi-polar disorder. A strong aversion toward scripture reading and prayer (especially one on one). A dark countenance (steely or hollow look in eyes - contraction of the pupils sometimes facial features contort or change - often an inability to look at you directly. Lying, exaggerating, or stealing compulsively (often wondering why).

41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59.

Drug abuse (especially when there are demonic hallucinations). Eating obsessions - bulimia, anorexia nervosa. Compulsive sexual sins, (especially perversions). Irrational laughter or crying. Bully, through Manipulation, Intimidation or Domination. Sudden speaking of a language not previously known (not gift of tongues) (often an ethnic language of ancestors). Reactions to the name and blood of Jesus Christ (verbally or through body language). Extreme restlessness (especially in a spiritual environment). Vulgar language and actions. Self humiliation. Loss of time (from minutes to hours - ending up someplace, not knowing how you got there - regularly doing things of which there is no memory). Extreme sleepiness around spiritual things. Demonstration of extraordinary abilities (either ESP or Telekinesis). Voices are heard in the mind (they mock, intimidate, accuse, threaten or bargain). Voice - refers to him/her in the third person. Supernatural experiences - haunting, movement or disappearance of objects, and other strange manifestations. Seizures (too long and/or too regular). Pain (without justifiable explanation - especially in head and/or stomach). Blackouts. Physical ailments can often be alleviated immediately by a command of spiritual authority (i.e. epileptic seizure, asthma attacks, and various pains).

Sudden interference with bodily functions (temporary) - buzzing in ears, inability to speak or hear, sudden severe headache, hypersensitivity in hearing or touch, sudden chills or overwhelming heat in body, numbness in arms or legs, temporary paralysis. When in doubt ... cast them out!
60.

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