Persona l History Questionnaire Page 1 __________________________________________________________________________________
PERSONAL HISTORY QUESTIONNAIRE
Written by Willard F. Harley, Jr.
Name:__________________________________________ Date:_________________________
Please answer all of the following questions as honestly and thoughtfully as possible. If your answer requires additional space, please use another page.
When answering, it is important to remember the Rule of Honesty and its five parts:
1. Emotional Honesty: Reveal your emotional reactions � both positive and negative � to the events of your life, particularly to your spouse�s behavior.
2. Historical Honesty: Reveal information about your personal history, particularly events that demonstrate personal weaknesses and failures.
3. Current Honesty: Reveal information about the events of your day. Provide your spouse with a calendar of your activities, with special emphasis on those that may affect your spouse.
4. Future Honesty: Reveal your thoughts and plans regarding future activities and objective.
5. Complete Honesty: Do not leave your spouse with a false impression about your thoughts, feelings, habits, likes, dislikes, personal history, daily activities, or plans for the future. Do not deliberately keep personal information from your spouse.
I agree to consider this information confidential and will not share any information revealed in this questionnaire to anyone without my spouse�s permission. I also agree to reward honesty and not punish my spouse for revealing any new information to me that I may find upsetting.
Signature of Spouse ____________________________________ � 1998 by Willard F. Harley, Jr.
www.marriagebuilders.comThe Rule of Honesty for Successful Marriage
Reveal to your spouse as much information about yourself as you know: Your thoughts, feelings,
habits, likes, dislikes, personal history, daily activities, and plans for the future
Persona l History Questionnaire Page 2 __________________________________________________________________________________
Health History
List childhood diseases, injuries or operations: ____________________________________________ __________________________________________________________________________________ List past adult diseases, injuries or operations: _____________________________________________ __________________________________________________________________________________ List present diseases or injuries (include high blood pressure, arthritis, migraine headaches, etc.) __________________________________________________________________________________ When did you have your last complete physical examination? ________________________________ What were the results? Did the doctor find a medical problem or are you generally in good health? __________________________________________________________________________________ How long does it take you to fall asleep? ________ How many hours do you sleep? _________
How often do you awaken? _______ How long does it take to get back to sleep? ___________
How many pounds have you gained and/or lost in the past year? ___________
Describe any of your past and present diet programs: _______________________________________
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Describe your exercise program: _______________________________________________________
What drugs do you presently take, what dosages, how often and why? _________________________
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Have you been hospitalized or received therapy for a mental disorder? If so, list hospital(s) and/or therapist(s) and approximate dates:
__________________________________________________________________________________ __________________________________________________________________________________
� 1998 by Willard F. Harley, Jr.
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Do you or have you ever had venereal disease? If so, when and what were the conditions (describe below):
� 1998 by Willard F. Harley, Jr.
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Family History
Mother�s Name: _________________________________________ Age: _____________________ Occupation: ____________________________ Education: _________________________________ How did she punish you? _____________________________________________________________ How did she reward you? _____________________________________________________________ What did she punish? ________________________________________________________________ What did she reward? ________________________________________________________________ How would others describe your mother? ________________________________________________ How would you describe your mother? __________________________________________________ What activities did you do with your mother when you were a child? __________________________ __________________________________________________________________________________ How did you get along with your mother? ________________________________________________ Father�s Name: _________________________________________ Age: ______________________ Occupation: ____________________________ Education: _________________________________ How did he punish you? ______________________________________________________________ How did he reward you? ______________________________________________________________ What did he punish? _________________________________________________________________ What did he reward? _________________________________________________________________ How would others describe your father? __________________________________________________ How would you describe your father? ____________________________________________________
� 1998 by Willard F. Harley, Jr.
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What activities did you do with your father when you were a child? ____________________________ __________________________________________________________________________________ How did you get along with your father? _________________________________________________
Names(s) of Brother(s) and Sister(s) Birth Date How did you get along with him/her?
Does (did) your mother or father favor any one? If so, who and why? _________________________ __________________________________________________________________________________ Were your natural mother and father divorced? If so, why and how old were you? __________________________________________________________________________________ How do (did) your mother and father get along? ___________________________________________ __________________________________________________________________________________ Was your father or mother (or both) alcoholic? If so, how did it effect your childhood? __________________________________________________________________________________ __________________________________________________________________________________ Describe any instances of physical violence or sexual advances to you by a parent or siblings when you were a child. ____________________________________________________________________ __________________________________________________________________________________
� 1998 by Willard F. Harley, Jr.
www.marriagebuilders.comPersona l History Questionnaire Page 6 __________________________________________________________________________________
If you were raised by step parents, foster parents or adoptive parents, please describe your most important experiences with them below.
� 1998 by Willard F. Harley, Jr.
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Educational History
What pre-school(s) did you attend? _____________________________________________________ Describe any significant experiences: ___________________________________________________ What grammar school(s) did you attend? _________________________________________________ What were your grades? _________ Describe any significant experiences: _____________________ __________________________________________________________________________________ What middle and/or secondary school(s) did you attend? ____________________________________ __________________________________________________________________________________ What were your grades? _________ Describe any significant experiences: _____________________ __________________________________________________________________________________ What college(s) did you attend? ________________________________________________________ What were your grades? _________ Describe any significant experiences: _____________________ __________________________________________________________________________________ What was your major? ______________________ Degree and date earned: ____________________ What post- graduate school(s) did you attend? _____________________________________________ What were your grades? _________ Describe any significant experiences: _____________________ __________________________________________________________________________________ What was your major? ______________________ Degree and date earned: ____________________
� 1998 by Willard F. Harley, Jr.
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Describe musical instruments played, sports or other extra-curricular activities in which you participated and awards you received throughout your education.
__________________________________________________________________________________ What are your future educational plans? _________________________________________________ __________________________________________________________________________________
� 1998 by Willard F. Harley, Jr.
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Vocational History
List the jobs you have held with the present or most recent job first. Under �Liked,� indicate what you liked about the job. Under �Disliked,� indicate what you disliked (use separate sheet if necessary).
Dates Job Title Salary Liked Disliked
How often do you miss work? Jobs you enjoy: _______ Jobs you dislike: _______ Describe how well you get along with your fellow employees. _______________________________ __________________________________________________________________________________ Describe how well you get along with your supervisor(s). ___________________________________ __________________________________________________________________________________ What training or education have you had relevant to your present occupation? __________________________________________________________________________________ Does your job satisfy you: Intellectually? Y/N ; Emotionally? Y/N ; Physically? Y/N What are your vocational ambitions? ____________________________________________________ __________________________________________________________________________________ What were your childhood interests and hobbies? __________________________________________ __________________________________________________________________________________ What are your present leisure time interests and hobbies? ____________________________________ __________________________________________________________________________________
� 1998 by Willard F. Harley, Jr.
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Religious History
What is the name of your religion? ______________________________________________________ Describe your most important religious beliefs. ____________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ How do your religious beliefs influence the decisions you make in your life? ____________________ __________________________________________________________________________________ __________________________________________________________________________________ List your religious activities and frequency of participation (prayer, study, meetings, etc.): __________________________________________________________________________________ __________________________________________________________________________________ Describe how your religious beliefs and those of your parents effected yo ur childhood? __________________________________________________________________________________ __________________________________________________________________________________ Describe any differences between your religious beliefs and those of your spouse: __________________________________________________________________________________ __________________________________________________________________________________ Have you made any important changes in your religious beliefs during your lifetime? __________________________________________________________________________________ __________________________________________________________________________________
� 1998 by Willard F. Harley, Jr.
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Opposite Sex Relationship History
List all significant opposite sex relationships you had prior to High School (use separate sheet of paper if needed):
Your Other�s How Long Did Were You Sexual Name Age Age the Relationship Last? in Love? Relationship?
List all significant opposite sex relationships you had during High School (use separate sheet of paper if needed):
Your Other�s How Long Did Were You Sexual Name Age Age the Relationship Last? in Love? Relationship?
List all significant opposite sex relationships you had after High School (use separate sheet of paper if needed):
Your Other�s Name Age Age
How Long Did the Relationship Last?
Were You Sexual in Love? Relationship?
� 1998 by Willard F. Harley, Jr.
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If you have been divorced, answer the following:
Date Date Reason Name(s) and Date(s) of Name Married Divorced For Divorce Birth of Child(ren)
If you have been divorced, describe the history of your relationship from the time you met to the present. Include information about what you liked most and what you disliked most about each individual.
__________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________
If you have been widowed, answer the following:
Date Date of Cause Name(s) and Date(s) of Name Married Death of Death Birth of Child(ren)
If you have been widowed, describe the history of your relationship from the time you met to death of your former spouse. Include information about what you liked most and what you disliked most about this person.
__________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________
� 1998 by Willard F. Harley, Jr.
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Sexual History
When and how did you first learn about sex? _____________________________________________ __________________________________________________________________________________ How did your parents influence your attitude regarding sex? _________________________________ __________________________________________________________________________________ What was your parents� attitude concerning sex? (circle one of the following)
1. 2. 3. 4.
Sex was shameful and not to be discussed. Sex was not shameful, but it wasn�t discussed. Sex was shameful, but was also discussed. Sex was not shameful and freely discussed.
Describe your first sexual experience: ___________________________________________________ __________________________________________________________________________________ Describe your most important sexual experiences and how they influenced the way you think about sex today: _____________________________________________________________________________ __________________________________________________________________________________ When and how did you first experience sexual arousal and how did you feel about it? __________________________________________________________________________________ __________________________________________________________________________________ When and how did you first experience sexual climax and how did you feel about it? __________________________________________________________________________________ __________________________________________________________________________________
� 1998 by Willard F. Harley, Jr.
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If you ever masturbated, when did you start? ______________________________________________ How often did you masturbate during childhood? __________ Through adolescents? _____________ What sexual fantasies do you have when you masturbate? ___________________________________
When did you first have sexual intercourse and how did the experience effect you?
__________________________________________________________________________________
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With how many people have you had sexual intercourse? ____________________________________
Have you ever had sexual experiences or fantasies about being treated violently? _________________
Sexual experiences or fantasies about treating others violently? _______________________________
Sexual experiences or desire to expose yourself in public? ___________________________________
Sexual experiences or desire to have sexual contact with children? _____________________________
Have you ever been in legal trouble because of your sexual behavior? If so, please describe the behavior and circumstances.
__________________________________________________________________________________
Have you ever had an extramarital sexual relationship(s)? If so, please describe it. __________________________________________________________________________________
Have you ever had a homosexual experience(s)? If so, please describe it. __________________________________________________________________________________ For the wife: When did you have your first period? _____________ Are they regular? ___________ When do they occur? ________________________ Are they comfortable? _____________________ Do they cause you to feel depressed, anxious or irritable? ____________________________________
� 1998 by Willard F. Harley, Jr.
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Personal Assessment Describe some of your fears: ___________________________________________________________ __________________________________________________________________________________
Describe faults you think you have: _____________________________________________________ __________________________________________________________________________________ Describe your good characteristics: ______________________________________________________ __________________________________________________________________________________ If you ever have any of the thoughts listed below, check the frequency of occurrence:
Type of Thought I am lonely.
The future is hopeless. Nobody cares about me. I feel like killing myself. I am a failure. I am intellectually inferior. I am going to faint. I am going to panic. People usually don�t like me.
Hardly Ever
Occasionally Frequently
Other negative thoughts you may have occasionally or frequently: _____________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________
� 1998 by Willard F. Harley, Jr.
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Indicate the degree that the following problems are a concern to you using this scale:
X = concern in the past, not now; 0 = never a concern; 1 = very slight degree of concern; 2 = mild degree of concern; 3 = moderate degree of concern; 4 = severe degree of concern; 5 = very severe degree of concern.
Sadness. Suicidal feelings. Loss of energy. Low self-esteem. Isolation and loneliness. Sleep disturbance. Headaches. Dizziness. Angry feelings. Mood swings. Verbal or emotional abuse. Physical abuse. Sexual abuse. Financial problems. Career problems. Marital problems. Parent/Child problems.
� 1998 by Willard F. Harley, Jr.
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Goals for Personal Improvement
Below is a list of bad habits that may include some that are making you feel anxious and depressed. Check off any habits that you would like to change:
Drinking alcoholic beverages too much. Smoking too much. Using drugs too much: Name the drug(s) ________________________ Eating too much. Exercising too little. Feeling too much attraction to members of my own sex. Feeling too much attraction to members of the opposite sex. Feeling nauseated when nervous. Thinking depressing thoughts. Feeling anxious in crowds. Feeling anxious in high places. Worrying about my health. Feeling anxious in airplanes. Stuttering. Washing my hands too often. Cleaning and straightening things up too often. Biting my fingernails. Being careless of my physical appearance. Feeling anxious in enclosed places.
� 1998 by Willard F. Harley, Jr.
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Feeling anxious in open places. Being too afraid of blood. Feeling anxious about contamination or germs. Feeling anxious about being alone. Feeling afraid of darkness. Feeling afraid of certain animals. Thinking the same thoughts over and over. Counting my heartbeats. Hearing voices. Feeling people are against me or out to get me. Seeing visions or objects that aren�t really there. Wetting the bed at night or having difficulty controlling my bladder. Having difficulty controlling my bowel movement. Taking too much medicine. Having too many headaches. Gambling too much. Being unable to fall asleep at night. Exposing my body to strangers. Wearing clothes of the opposite sex. Feeling sexually attracted to other people�s clothing or belongings. Feeling sexually attracted to children. Feeling sexually attracted to animals.
� 1998 by Willard F. Harley, Jr.
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Feeling sexual desire to hurt other people. Feeling sexual desire to be hurt or humiliated. Feeling non-sexual desire to hurt other people. Feeling non-sexual desire to be hurt or humiliated. Stealing or a desire to steal. Lying. Yelling at people when I�m angry. Poor management of money. Saying foolish things to people. Having difficulty carrying on a conversation with people. Bothering or irritating people too much. Forgetfulness. Contemplating suicide. Setting fires or a desire to set fires. Difficulty being steadily employed. Feeling uncomfortable at work. Swearing. Being too upset when criticized by others. Difficulty expressing my feelings. Putting things off that need to be done. Thinking things that make me feel guilty. Feeling anxious when my work is being supervised.
� 1998 by Willard F. Harley, Jr.
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Feeling anxious about sexual thoughts. Feeling anxious about kissing. Feeling anxious about petting. Feeling anxious about sexual intercourse. Having difficulty making decisions when they need to be made. Feeling uncomfortable with groups of people.
Feeling anxious about: ________________________________________________ Feeling depressed about: ______________________________________________ Feeling guilty about: _________________________________________________ Being unable to control my desire to: ____________________________________
How do you plan to change the habits checked above? ______________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________
� 1998 by Willard F. Harley, Jr.
www.marriagebuilders.com
