Name:

How old are you? What is your gender? What is your sex?
What type of family structure do you have?
Do you consider your family a closely-knit family?
How many times in a week does your family spend time together?

What is the present age of your father? What is the present age of your mother?
How many siblings are there in your family?
What is your hierarchy level in your family?
Please state your siblings age according to hierarchy.

Are your parents still all alive?

If yes, who decides primarily?
If both, which has the last word?
Are both your parents working?
Which parent is the primary breadwinner?

If no, please state your age when your parent/parents died.

Which parent is deceased? Are you close with your deceased parent?

Are your parents abroad?

If yes, please state which parent went abroad?
What was your age when your parent/parents left for abroad?
How long where your parent/parents been abroad?
When was the last time you shared time with your abroad parent/parents?
Do you maintain a continuous contact with one another?
How often?
What was the mode of communication you always used?
Do you feel satisfied with your communication?

In your family, whom do you consider closest to you aside from your parents?
If you are made to decide, which parent are you comfortable to discuss intimate details of your life, problems and
secrets?
What makes you feel comfortable to discuss your life with your close parent?

Are you in a relationship right now?

How long already?
How many previous relationships have you been before?

1. Please re-write this at the back of this paper.

Humans are far different from other forms of life. They tend to choose their mates according to a variety of pre-conceived beliefs,
notions and set of behavior that unconsciously decides without dealing the consciousness of weighing the rationales, logic and
motive of such choice. Since birth we are programmed to come up with that choice. Ironically, you dont have a choice. Your
psyche is formatted to address the choice once it leads to a choice.

2. After re-writing these preceding sentences, please write your opinion regarding the short write up at the back of this paper.

3. Please write A-Z in your own handwriting at the back of this paper. Do not use block form.

4. Please write numbers 0-9 in your own handwriting.

5. At the end of this exercise, please write your own signature 5 times.

Thanks a lot!

Marlon Rey Anacleto, RN, MAN