CLINICAL PSYCHOLOGY – PSYCHOLOGICAL TESTING AND ASSESSMENT

I. PERSONAL INFORMATION

a. Name:

b. Sex:

c. Occupation:

d. Address:

e. Date and place of birth:

f. Civil status:

g. Religion:

h. Educational attainment:

II. HISTORY OF THE ILLNESS

a. Dates of the first onset and recurrences of illness:

b. Consultations:

c. Hospital admissions:

d. Medications:

e. Perceived triggers for onset of symptoms:

III. PRESENT SITUATION (desc. of daily behavior or any impending changes.)

 IV. EDUCATION AND TRAINING

a. Favorite subject/s:

b. Achievement/s

c. Varsity? Scholar? Bullied?

V. Family of origin (description of family members and the respondent’s role in the family he grew

up)

VI. HEALTH

a) Physical functioning

b) Medical history (childhood and later injuries)

c) Present illnesses

d) Medications (eating, sleeping, exercise, suicide attempts)

VII. SUBSTANCE ABUSE: alcohol, cigarettes, drugs

VIII. SEXUAL DEVELOPMENT (first awareness, sexual practice (kinds of sexual activities and view of

the sexual expressions))

IX. WORK HISTORY (date, periods, reason for changing jobs and attitudes toward work and

authority, relationship with peers/coworkers)

 X. INTERPERSONAL RELATIONSHIPS (friendships, social engagement with groups of community,

quality of relationships)

XI. RECREATIONS AND INTERESTS (respondent’s report of adequacy of self-expression and

pleasures)

a) Hobbies:

b) Sports:

c) Volunteer works:

XII. RELIGIOUS BACKGROUND (religious or spiritual practice, significant spiritual experience,

perception of one’s religiosity and spirituality)

XIII. SELF-DESCRIPTION

a) Strengths:

b) Weaknesses:

c) Ideals:

XIV. CHOICES AND TURNING POINTS IN LIFE (most important decisions and changes in life)

XV. VIEW OF THE FUTURE (plans and dreams for the future, what the respondent would like to see

happen next year and in five or ten years, and what is necessary for these events to happen)