Name:
Applying as:
Select
Patient
Trainee
How did you find out about:
Primal Therapy?:
Select
The Primal Scream
The New Primal Scream
Why You Sick, How You Get Well
The Biology Of Love
Other (Please Specify)
If other, please specify:
The Primal Center?:
Select
Books
Referral
Word of Mouth
Patients
Other (Please Specify)
If other, please specify:
Have you read any of Dr. Arthur Janov's books?:
Select
Yes
No
If yes, which one(s)?:
Contact Information:
Email:
Tel.:
Fax:
Address:
City:
State/Prov:
Country:
Zip Code:
Nationality:
Personal Information
Languages Spoken:
Age:
Birth Date:
Sex:
Select
Male
Female
Education:
Select
9-12 Years in school
University graduate
Graduate of professional school
Profession:
Spouse's profession:
Weight:
Height:
Current marital status:
Select
Single
Married
Divorced
Number of children and ages:
Religion:
Country and area where you spent the
majority of your childhood:
Number of children in family:
Which number child were you in your family?:
You were raised for the majority of your
childhood by:
Select
Single mother
Single father
Other (explain)
If other, please specify:
During your childhood were you sent away
from your natural home?:
Select
Yes
No
If yes, indicate where:
To live with relatives
To boarding schoo
To a foster home
To an institution
Family's economic status during childhood:
Birth Information
What kind of birth did you have?:
Select
Normal Delivery
Forceps delivery
Caesarean section
Breach delivery
Multiplepregnancy (i.e. were you a twin, triplet, etc)
Indicate (if known) the circumstances at
the time of your birth delivery (number of weeks):
Select
Full Term
Premature
Post Term
Duration of labor in hours:
Were you below normal weight for your
gestation age at the time of delivery:
Select
Yes
No
Did your mother receive pain relieving drugs or
anesthesia during labor??
If yes, indicate which:
Did you require active resuscitation after birth
(as needed with babies born blue)?:
Select
Yes
No
Did you spend time in an incubator or a special
baby unit after birth?:
Select
Yes
No
Were you circumcised shortly after birth?:
Select
Yes
No
Were you breast fed?:
Select
Yes
No
Medical Information
Do you have suicidal impulses?:
Select
Yes
No
If yes:
Frequently
Rarely
Have you ever attempted suicide?:
Select
Yes
No
If yes, indicate method:
Have you ever been admitted to a hospital
for psychiatric treatment?:
Select
Yes
No
If yes, how many times?:
Total duration of stay:
Have you ever been raped?:
Select
Yes
No
If yes, was it incestuous?:
Yes
No
Were you ever molested?:
Select
Yes
No
If yes, by whom?:
For how long?:
Do you use recreational drugs, or have
you used them in the past?:
Select
Yes
No
If yes, which and for how long?:
If LSD, how many trips? When?:
If cannabis/hashish, for how long?:
Are you currently on tranquilizers?:
Select
Yes
No
Which? Dosage?:
Are you taking any (other) prescription
medication? Which? How often?:
Are you subject to heavy use of alcohol?:
Select
Yes
No
Have you ever been diagnosed as being alcoholic?:
Select
Yes
No
If yes, have you had treatment for this?:
Yes
No
Do you regularly smoke tobacco?:
Select
Yes
No
If yes, how many cigarettes per day?:
On average how many cups of tea/coffee
do you drink per day?:
Do you regularly suffer from any of the following
features of anxiety (see list in box just below
"If yes, indicate appropriately")?:
Select
Yes
No
If yes, indicate appropriately:
Panic attacks
Apprehension or fear
Shaking or trembling
Inability to relax
Easily fatigued
Anticipation or misfortune to self or others
Startle reactions
Impatience
Other
If other, please specify:
Are you subject to depression?:
Select
Yes
No
If yes, is it:
Severe
Frequent
Mild
Rare
Do you suffer from phobias?:
Select
Yes
No
If yes, indicate which:
Are you subject to recurrent thoughts
that enter your mind in an obsessive fashion?:
Select
Yes
No
Do you have frequent muscle tension?:
Select
Yes
Do you have high blood pressure?:
Select
Yes
No
If yes, are you on medication for this?:
Yes
No
What type?:
Are you subject to palpitation? (where you
feel your heart beating rapidly):
Select
Yes
No
Are you subject to excessively cold
hands and/or feet?:
Select
Yes
No
Have you been diagnosed to have any other
disease of the heart or circulation?:
Select
Yes
No
If yes, indicate diagnosis:
Do you have asthma?:
Select
Yes
No
If yes, have you been hospitalized?:
Yes
No
Do you have tension headache?:
Select
Yes
No
If yes, is it:
Severe
Mild
Frequent
Rare
Do you suffer with migraine which has
been medically diagnosed?:
Select
Yes
No
If yes, are attacks:
Frequent
Rare
Are your menstrual periods usually regular?:
Select
Yes
No
Do you suffer from P.M.S.?:
Select
Yes
No
On average how many hours sleep
do you have per night?:
Do you feel rested when you get
up in the morning?:
Select
Occasionally
Rarely
Do you usually have difficulty in falling asleep?:
Select
Frequently
Rarely
No
Do you use hypnotic drugs
(sleeping pills) to ensure sleep?:
Select
Every Night
Occasionally
No
If yes, indicate which:
Do you have nightmares?:
Select
Frequently
Rarely
No
If yes, indicate general theme:
Are you active in?:
Select
Homosexual fantasies
Voyeurism
Transvestism
Frequent desire for pornographic literature
Exhibitionism
Fantasies or impulses to rap
Fantasies of being raped
Sadomasochism
Other
Additional information, if necessary:
Is your sexual preference predominantly?:
Select
Heterosexual
Homosexual
Bi-Sexual
Have you had any of the following psychological treatments? Please check any that you have had:
Psychoanalysis:
Transactional analysis:
Behavior modification:
Bioenergetics:
Transcendental meditation:
Hypnotherapy:
Biofeedback:
Rebirthing:
Electro-shock:
Drug therapy:
Co-counseling:
Other Information
Do you ever cry?:
Select
Yes
No
When was the last time you cried?:
Have you had previous Primal Therapy?:
Select
Yes
If yes, Where?:
With whom?:
When?:
For how long?:
Why did you stop?:
Social life: How would you rate it?:
Select
Good
Mediocre
Bad
Episodic
Work history? Briefly list last
5 years' work: Occupation & Duration:
Do you have an intimately close relationship
with one or more persons in your life?:
Yes
No
If yes, how many close friends? For how long?: :
Do you have a close relationship with one
or both of your parents or your siblings?:
Select
Yes
No
If yes:
Father
Mother
Both Father & Mother
Brother(s)
Sister(s)
Have you ever been subjected to violence?:
Select
Yes
No
If yes, please explain:
Have you ever engaged in any violent behavior?:
Select
Yes
No
If yes, please explain:
What do you expect from the therapy?:
Why do you want to be a patient (or trainee)?:
How do you plan to finance
the therapy and follow up?:
When would you like to start
Primal Therapy (month and year)?:
Please type in the charaters you see to validate the form