- My favorite color is:
- My favorite flower is:
- My favorite candy is:
- My favorite chocolate bar is:
- My favorite movie is:
- My favorite song is:
- My favorite pet is:
- My favorite alcoholic drink is:
- How often do I drink alcoholic beverages?
- My favorite drink is:
- My favorite conversation topics are:
- My favorite book is:
- My favorite childhood cartoon was:
- My favorite childhood toy was:
- My preferred room temperature is:
- The toilet paper should come from the (top/bottom):
- I am (neat/messy):
- Three things I like most about me are:
- Three things I like least about me are:
- My greatest personal strength is:
- My greatest personal weakness is:
- The parts of my body I like most are:
- The parts of my body I like least are:
- Someone that I really admire is:
- What I fear most is:
- What I need most is:
- My most frequent mood is:
- I find my greatest joy in life when:
- I dislike people who:
- What hurts me the most is:
- An accomplishment I feel most proud of is:
- Something I feel the most regret about in my life is:
My History & Preferences
- Do I have a criminal record? What’s on it?
- Do I have any skeletons in my closet? (i.e. past trauma, previous relationships, etc.)
- Have I ever hit someone? Why?
- List childhood diseases, injuries or operations:
- List past adult diseases, injuries or operations:
- I had my last complete physical examination on ______________________.
- List present diseases or injuries (include high blood pressure, arthritis, migraine headaches, etc.)
Diet & Exercise
- How many pounds have you gained and/or lost in the past year?
- Describe any of your past and present diet programs:
- Describe your exercise program:
- What drugs do you presently take, what dosages, how often and why?
- Have you been hospitalized or received therapy for a mental disorder?
- What were your childhood interests and hobbies?
- What are your present leisure time interests and hobbies?
- Are there hobbies/activities we should do together that we aren’t currently doing?
- I have traveled to…
- I’d like to travel to…
- What is my ideal amount of alone time?
- I should communicate that to my partner by…
- How much TV should I watch?