Questionnaire

Official site of Primal Therapy

Dr Arthur Janov, Founder
Dr France Janov, Clinical Director

		Life Before Birth In bookstores in October 2011

(shipping cost: $10) This is Dr. Janov's opus magnum, a revolutionary work in every sense of the word. It may help to change the practice of psychotherapy as we know it, and above it, how we give birth today; the shoulds and should nots. It explains in detail how early trauma and adversity can have lifelong consequences and result in serious afflictions from cancer to diabetes. It can have monumental implications for medical practice, as well, and points to how we can rear healthy children.



		Sex & The Subconscious

Available on line Order now Here Dr Janov explores how trauma and lack of love stand in the way of millions of people as they try and experience sexual pleasure in life. Replete with case histories addressing a multitude of sexual difficulties, Janov explains how neuroscience and sexual history can combine to create the perfect storm of sexual dysfunction."




Dr. Arthur Janov's Blog www.arthurjanov.com Every week, read new articles by Dr Arthur Janov and answers from his readers.

Questionnaire for Prospective Patients

Please read the following before answering the questions in this questionnaire:

The information which you provide will be held in the strictest confidence. Videotaping is done as part of therapy for in-house use only. Should Dr. Janov's Primal Center decide to publish any of the information or statistical data gathered from the questionnaire, you will not be personally identified. Please read each question carefully before you respond. You may print out this questionnaire and mail it to us, or complete it here, online (when you are done, click on the "E-mail Questionnaire" button at the bottom).

Name:
Applying as:
How did you find out about:
Primal Therapy?:
	If other, please specify:
The Primal Center?:
	If other, please specify:
Contact Information:
Email:
Tel.:
Fax:
Address:
City:
State/Prov:
Country:
Zip Code:
Nationality:
Personal Information
Languages Spoken:
Age:
Birth Date:
Sex:
Education:
Profession:
Spouse's profession:
Weight:
Height:
Current marital status:
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:
	If other, please specify:
During your childhood were you sent away from your natural home?:
If yes, indicate where:
Family's economic status during childhood:
Birth Information
What kind of birth did you have?:
Indicate (if known) the circumstances at the time of your birth delivery (number of weeks):
Duration of labor in hours:
Were you below normal weight for your gestation age at the time of delivery:
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)?:
Did you spend time in an incubator or a special baby unit after birth?:
Were you circumcised shortly after birth?:
Were you breast fed?:
Medical Information
Do you have suicidal impulses?:
	If yes:
Have you ever attempted suicide?:
If yes, indicate method:
Have you ever been admitted to a hospital for psychiatric treatment?:
If yes, how many times?:
Total duration of stay:
Have you ever been raped?:
	If yes, was it incestuous?:
Were you ever molested?:
If yes, by whom?:
For how long?:
Do you use recreational drugs, or have you used them in the past?:
If yes, which and for how long?:
If LSD, how many trips? When?:
If cannabis/hashish, for how long?:
Are you currently on tranquilizers?:
Which? Dosage?:
Are you taking any (other) prescription medication? Which? How often?:
Are you subject to heavy use of alcohol?:
Have you ever been diagnosed as being alcoholic?:
	If yes, have you had treatment for this?:
Do you regularly smoke tobacco?:
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")?:
If yes, indicate appropriately:
	If other, please specify:
Are you subject to depression?:
	If yes, is it:
Do you suffer from phobias?:
If yes, indicate which:
Are you subject to recurrent thoughts that enter your mind in an obsessive fashion?:
Do you have frequent muscle tension?:
Do you have high blood pressure?:
	If yes, are you on medication for this?:
What type?:
Are you subject to palpitation? (where you feel your heart beating rapidly):
Are you subject to excessively cold hands and/or feet?:
Have you been diagnosed to have any other disease of the heart or circulation?:
	If yes, indicate diagnosis:
Do you have asthma?:
	If yes, have you been hospitalized?:
Do you have tension headache?:
	If yes, is it:
Do you suffer with migraine which has been medically diagnosed?:
	If yes, are attacks:
Are your menstrual periods usually regular?:
Do you suffer from P.M.S.?:
On average how many hours sleep do you have per night?:
Do you feel rested when you get up in the morning?:
Do you usually have difficulty in falling asleep?:
Do you use hypnotic drugs (sleeping pills) to ensure sleep?:
If yes, indicate which:
Do you have nightmares?:
If yes, indicate general theme:
Are you active in?:
Additional information, if necessary:
Is your sexual preference predominantly?:
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?:
When was the last time you cried?:
Have you had previous Primal Therapy?:
If yes, Where?:
With whom?:
When?:
For how long?:
Why did you stop?:
Social life: How would you rate it?:
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?:
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?:
If yes:
Why do you want to be a patient (or trainee)?:
What do you expect from the therapy?:
How do you plan to finance the therapy and follow up?:
Have you ever been subjected to violence?:
If yes, please explain:
Have you ever engaged in any violent behavior?:
If yes, please explain:
When would you like to start Primal Therapy (month and year)?:
Failure to enter these characters here will result in a loss of information in this form! Please type in the charaters you see to validate the form

Questionnaire for Prospective Patients

How did you find out about:

Contact Information:

Personal Information

Birth Information

Medical Information

Have you had any of the following psychological treatments? Please check any that you have had:

Other Information