Multimodal life history inventory (MMLHI) MMLHI Step 1 of 11 9% © 1991 by Arnold A. Lazarus and Clifford N. Lazarus This inventory has been placed online, but corresponds to purchased hard copies for each use.The purpose of this inventory is to obtain a comprehensive picture of your background. In psychotherapy, records are necessary since they permit a more thorough dealing with one's problems. By completing these questions as fully and accurately as you can, you will facilitate your therapeutic experience. You are requested to answer these questions on your own time, rather than utilizing your actual session time. It is understandable that you may be concerned about the what happens to the information about you because much or all of this information is highly personal. Case records are strictly confidential, as per our Informed Consent Agreement. NOTE: You MUST complete all required questions -- the assessment will not allow submissions that are incomplete in any way. If a section does not apply, please enter "n/a."Today's Date* MM slash DD slash YYYY GENERAL INFORMATIONFull Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone Number at Which Your Therapist Can Call/Text You*Email address* Date of Birth (MM/DD/YYYY)* MM slash DD slash YYYY Place of Birth* Age at time of completion* Occupation* Gender* Male Female Transgender M to F Transgender F to M Genderqueer (not exclusively male or female) Uncertain/Questioning Sexual Orientation/Identification* Straight or Heterosexual Lesbian, Gay, or Homosexal Bisexual Pansexual Asexual Don't Know/Questioning Religious/Spiritual Orientation* Height* Weight*Please enter a number from 50 to 500.Does your weight fluctuate?* Yes No If yes, by how much?Please enter a number from 0 to 100.Name of Physician* Phone number of Physician* How were you referred to us? (Please include multiple sources if applicable)* Relationship Status (Select ALL that apply)* Single Engaged Married Separated Divorced Widowed Domestic Partnership If remarried, how many times? Do you live in a ______?* House Apartment/Condo/Townhome Room With whom do you live)? (Select ALL that apply)* Self Only Parents Spouse/Partner(s) Children (my own) Children (others') Roomate Friends Other What sort of work are you doing now?*Does your present work satisfy you?* Yes No If no, please explain.What sort of jobs have you held in the past?*Have you ever been in therapy before or received any professional assistance for your problems?* Yes No Have you ever been hospitalized for psychological/psychiatric problems?* Yes No If yes, when and where? Please note facility/hosptial name(s), issue(s), and date(s).*Have you ever attempted suicide?* Yes No Does any member of your family suffer from an "emotional" or "mental disorder"?* Yes No Has any relative attempted or committed suicide?* Yes No PERSONAL & SOCIAL HISTORYParent/Guardian 1Age* Occupation* Health If deceased, age at time of death: If deceased, how old were you at the time of death? If deceased, cause of death: Parent/Guardian 2Age* Occupation* Health If deceased, age at time of death: If deceased, how old were you at the time of death? If deceased, cause of death: SiblingsAge(s) and Name(s)* Any significant details about siblings:*If you were not brought up by your parents, who raised you and between what years?Give a description of parent/guardian 1's personality and attitude toward you (past and present)*Give a description of parent/guardian 2's personality and attitude toward you (past and present)*Give an impression of your home atmosphere (i.e., the home in which you grew up). Mention state of compatibility between parents and children.*Were you able to confide in your parents?*YesNoBasically, did you feel loved and respected by your parents?*YesNoIf you have stepparents, give your age when your parent(s) remarried:Has anyone (parents, relatives, friends) ever interfered in your marriage, occupation, etc.?*YesNoIf yes, please describe briefly:Scholastic Strengths*Scholastic Weaknesses*What was the last grade completed or the highest degree?* Check ANY of the following that apply regarding your childhood/adolescence:* Happy childhood Unhappy childhood Emotional/behavior problems Legal trouble Death in the family Medical problems Ignored Not enough friends School problems Financial problems Strong religious convictions Drug use Used alcohol Severely punished Sexually abused Severely bullied or teased Eating disorder Others If you checked "others," briefly explain:DESCRIPTION OF PRESENTING PROBLEMSState in your own words the nature of your main problems*On this scale, please estimate the severity of your problem(s):*Mildly upsettingModerately upsettingVery severeExtremely severeTotally incapacitatingWhen did your problems begin?*What seems to worsen your problems?*How satisfied are you with your life as a whole these days?*What have you tried that has been helpful?*How would you rate your overall level of tension during the past month?*1 (Relaxed)234567 (Tense)Expectations Regarding TherapyIn a few words, what do you think therapy is all about?*How long do you think therapy should last?*What personal qualities do you think the ideal therapist should possess?* MODALITY ANALYSIS OF CURRENT PROBLEMS: The following section is designed to help you describe your current problems in greater detail and to idenitify problems that might otherwise go unnoticed. This will enable us to design a comprehensive treatment program and tailor it to your specific needs. The following section is organized according to the seven modalities of Behaviors, Feelings, Physical Sensations, Images, Thoughts, Interpersonal Relationships, and Biological Factors.BehaviorsCheck any of the following behaviors that apply to you: Overeat Take drugs Unassertive Odd Behavior Drink too much Work too hard Procrastination Impulsive reactions Loss of control Suicidal attempts Compulsions Smoke Withdrawal Nervous tics Concentration difficulties Sleep disturbances Phobic avoidance Spend too much money Can't keep a job Insomnia Take too many risks Lazy Eating problems Aggressive behavior Crying Outbursts of anger Others If you checked "others," briefly explain:What are some special talents or skills that you feel proud of?*What would you like to start doing?*What would you like to stop doing?*How is your free time spent?*What kind of hobbies or leisure activities do you enjoy or find relaxing?*Do you have trouble relaxing or enjoying weekends and vacations?*YesNoIf yes, please explain:*If you could have any two wishes, what would they be?* FeelingsCheck any of the following feelings that often apply to you:* Angry Annoyed Sad Depressed Anxious Fearful Panicky Energetic Envious Guilty Happy Conflicted Shameful Regretful Hopeless Helpless Relaxed Jealous Unhappy Bored Restless Lonely Contented Excited Optimistic Tense Others If you checked "others," briefly explain:*List your 5 main fears:*1. 2. 3. 4. 5.What are some positive feelings you have experienced recently?*When are you most likely to lose control of your feelings?*Describe any situations that make you feel calm or relaxed:* Physical SensationsCheck any of the following physical sensations that often apply to you:* Abdominal Pain Pain or burning with urination Menstrual difficulties Headache Dizziness Palpitations Muscle Spasms Tension Sexual disturbances Unable to relax Bowel disturbances Tingling Numbness Stomach trouble Tics Fatigue Twitches Back pain Tremors Fainting Spells Hear things Watery eyes Flushes Nausea# Skin problems Dry Mouth Burning or itching skin Chest pains Rapid heart beat Don't like to be touched Blackouts Excessive sweating Visual disturbances Hearing problems Others If you checked "others," briefly explain:*What physical sensations are pleasant for you?*What physical sensations are unpleasant for you?*ImagesCheck any of the following that apply to you. I picture myself:* Being happy Being hurt Not coping Succeeding Losing control Being followed Being talked about Being aggressive Being helpless Hurting others Being in charge Failing Being trapped Being laughed at Being promiscuous Others If you checked "others," briefly explain:*I have:* Pleasant sexual images Unpleasant childhood images Negative body image Unpleasant sexual images Lonely images Seduction images Images of being loved Others If you checked "others," briefly explain:*Describe a very pleasant image, mental picture, or fantasy:*Describe a very unpleasant image, mental picture, or fantasy:*Describe your image of a completely "safe place":*Describe any persistent or disturbing images that interfere with your daily functioning:*How often do you have nightmares?* ThoughtsCheck each of the following that you might use to describe yourself:* Intelligent Confident Worthwhile Ambitious Sensitive Loyal Trustworthy Full of regrets Worthless A nobody Useless Evil Crazy Morally degenerate Considerate Deviant Unattractive Unlovable Inadequate Confused Ugly Stupid Naive Honest Incompetent Horrible thoughts Conflicted Concentration difficulties Memory problems Attractive Can't make decisions Suicidal ideas Persevering Good sense of humor Hard working Undesireable Lazy Untrustworthy Dishonest Others If you checked "others," briefly explain:*What would you consider to be your craziest thought or idea?*Are you bothered by thoughts that occur over and over again?*What worries do you have that may negatively affect your mood or behavior?*On each of the following items, please select the number that most accurately reflects your opinion:I should not make mistakes.* 1 (Strongly Disagree) 2 (Disagree) 3 (Neutral) 4 (Agree) 5 (Strongly Agree) I should be good at everything I do.* 1 (Strongly Disagree) 2 (Disagree) 3 (Neutral) 4 (Agree) 5 (Strongly Agree) When I do not know something, I should pretend that I do.* 1 (Strongly Disagree) 2 (Disagree) 3 (Neutral) 4 (Agree) 5 (Strongly Agree) I should not disclose personal information.* 1 (Strongly Disagree) 2 (Disagree) 3 (Neutral) 4 (Agree) 5 (Strongly Agree) I am a victim of circumstances.* 1 (Strongly Disagree) 2 (Disagree) 3 (Neutral) 4 (Agree) 5 (Strongly Agree) Other people are happier than I am.* 1 (Strongly Disagree) 2 (Disagree) 3 (Neutral) 4 (Agree) 5 (Strongly Agree) It is very important to please other people.* 1 (Strongly Disagree) 2 (Disagree) 3 (Neutral) 4 (Agree) 5 (Strongly Agree) Play it safe; don't take any risks.* 1 (Strongly Disagree) 2 (Disagree) 3 (Neutral) 4 (Agree) 5 (Strongly Agree) I don't deserve to be happy.* 1 (Strongly Disagree) 2 (Disagree) 3 (Neutral) 4 (Agree) 5 (Strongly Agree) If I ignore my problems, they will disappear.* 1 (Strongly Disagree) 2 (Disagree) 3 (Neutral) 4 (Agree) 5 (Strongly Agree) It is my responsibility to make other people happy.* 1 (Strongly Disagree) 2 (Disagree) 3 (Neutral) 4 (Agree) 5 (Strongly Agree) I should strive for perfection.* 1 (Strongly Disagree) 2 (Disagree) 3 (Neutral) 4 (Agree) 5 (Strongly Agree) Basically, there are two ways of doing things: the right way and the wrong way.* 1 (Strongly Disagree) 2 (Disagree) 3 (Neutral) 4 (Agree) 5 (Strongly Agree) I should never be upset.* 1 (Strongly Disagree) 2 (Disagree) 3 (Neutral) 4 (Agree) 5 (Strongly Agree) Interpersonal RelationshipsFriendshipsDo you make friends easily?* Yes No Do you keep them?* Yes No Did you date much during adolescence?* Yes No Did you date (/are you dating) much during your 20's? Yes No Were you ever bullied or severely teased?* Yes No Describe any relationship that gives you joy.*Describe any relationship that gives you grief.*Rate the degree to which you generally feel relaxed and comfortable in social situations:* 1 (Very Relaxed) 2 (Mostly Relaxed) 3 (Somewhat Anxious) 4 (Neutral -- neither relaxed nor anxious) 5 (Somewhat Anxious) 6 (Mostly Anxious) 7 (Very Anxious) Do you have one or more friends with whom you feel comfortable sharing your most private thoughts?* Yes No Marriage/Committed Relationships & FamilyAre you currently married?* Yes No How long did you know your spouse before your engagement?* How long were you engaged before you got married?* How long have you been married?* Are you currently in a committed relationship?* Yes No What is your partner's age and occupation?* Describe your partner's personality:*What do you like least about your partner?*What factors detract from your relational satisfaction?*Please indicate how satisfied you are with your relationship:* 1 (Very Dissatisfied) 2 (Mostly Dissatisfied) 3 (Somewhat Dissatisfied) 4 (Neutral -- neither Satisfied nor Dissatisfied) 5 (Somewhat Satisfied) 6 (Mostly Satisfied) 7 (Very Satisfied) How do you get along with your partner's friends and family?* 1 (Very Poorly) 2 (Mostly Poorly) 3 (Somewhat Poorly) 4 (Neutral -- neither Well nor Poorly) 5 (Somewhat Well) 6 (Mostly Well) 7 (Very Well) Please describe any previous marriages or longterm relationships, including length of time, current status, and reason for divorce/separation/relational ending.*How many children do you have?*0123456 or morePlease give their names and ages:*Do any of your children present special problems, struggles, or difficulties?* Sexual RelationshipsDescribe your parents' attitude toward sex. Was sex discussed in your home?*When and how did you derive your first knowledge of sex?*When did you first become aware of your own sexual impulses?*Have you ever experienced anxiety or guilt arising out of sex or masturbation? If yes, please elaborate.*Are there any relevant details your therapist should know regarding your first or subsequent sexual experiences?*Is your present sex life satisfactory?* Yes No If no, please explain:*Please note any concerns or desires for therapy related to sex not discussed above:* Other RelationshipsAre there any problems in your relationships with people at work? If yes, please describe.*Are there any problems in your relationships with people in social, civic, religious/spiritual, or other communities?*Please complete the following. One of the ways people hurt me is:* I could shock you by:* My spouse (boyfriend/girlfriend) would describe me as:* My best friend thinks I am:* People who dislike me:* Are you currently troubled by any past rejections or loss of a love relationship? If yes, please describe.* Biological FactorsDo you have any current concerns about your physical health? If yes, please describe.*Please list any medications you are currently taking:*Do you eat multiple well-balanced meals a day?* Yes No Do you get regular physical exercise?* Yes No If yes, what type and how often?*Please list any significant medical problems that apply to you or members of your family:*Please describe any surgery you have had (give dates):*Please describe any physical impairment(s) or limitation(s) you have:*Do you menstruate?* Yes No Age at first period:* Had you been informed/educated?* Yes No Did it come as a shock?* Yes No Is your cycle regular?* Yes No How many days are in your cycle?* Do you have pain?* Yes No Do your periods affect your moods?* Yes No Date of last period:* Muscle weakness* Never Rarely Occasionally Frequently Daily Tranquilizers* Never Rarely Occasionally Frequently Daily Diuretics* Never Rarely Occasionally Frequently Daily Diet pills* Never Rarely Occasionally Frequently Daily Cannabis* Never Rarely Occasionally Frequently Daily Hormones* Never Rarely Occasionally Frequently Daily Sleeping Pills* Never Rarely Occasionally Frequently Daily Aspirin or Ibuprofen* Never Rarely Occasionally Frequently Daily Cocaine* Never Rarely Occasionally Frequently Daily Painkillers* Never Rarely Occasionally Frequently Daily Benzos* Never Rarely Occasionally Frequently Daily Stimulants* Never Rarely Occasionally Frequently Daily Hallucinogens* Never Rarely Occasionally Frequently Daily Laxatives* Never Rarely Occasionally Frequently Daily Cigarettes* Never Rarely Occasionally Frequently Daily Other tobacco* Never Rarely Occasionally Frequently Daily Coffee* Never Rarely Occasionally Frequently Daily Alcohol* Never Rarely Occasionally Frequently Daily Birth Control* Never Rarely Occasionally Frequently Daily Vitamins* Never Rarely Occasionally Frequently Daily Undereat* Never Rarely Occasionally Frequently Daily Overeat* Never Rarely Occasionally Frequently Daily Junk food* Never Rarely Occasionally Frequently Daily Diarrhea* Never Rarely Occasionally Frequently Daily Constipation* Never Rarely Occasionally Frequently Daily Gas* Never Rarely Occasionally Frequently Daily Indigestion* Never Rarely Occasionally Frequently Daily Nausea* Never Rarely Occasionally Frequently Daily Vomiting* Never Rarely Occasionally Frequently Daily Heartburn/Acid Reflux* Never Rarely Occasionally Frequently Daily Dizzyness* Never Rarely Occasionally Frequently Daily Palpitations* Never Rarely Occasionally Frequently Daily Fatigue* Never Rarely Occasionally Frequently Daily Allergies* Never Rarely Occasionally Frequently Daily High Blood Pressure* Never Rarely Occasionally Frequently Daily Chest Pain* Never Rarely Occasionally Frequently Daily Shortness of Breath* Never Rarely Occasionally Frequently Daily Sleep too much* Never Rarely Occasionally Frequently Daily Fitful sleep* Never Rarely Occasionally Frequently Daily Early morning waking* Never Rarely Occasionally Frequently Daily Earaches* Never Rarely Occasionally Frequently Daily Headaches* Never Rarely Occasionally Frequently Daily Back aches* Never Rarely Occasionally Frequently Daily Bruise or bleed easily* Never Rarely Occasionally Frequently Daily Weight problems* Never Rarely Occasionally Frequently Daily Are there other biological factors we should know about?* Yes No If yes, please specify and provide descriptions and durations:* Structural ProfileBEHAVIORS: Some people may be described as "doers" - they are action oriented, and like to busy themselves, get things done, take on various projects. How much of a doer are you?* 1 (Lowest) 2 3 4 5 6 7 (Highest) FEELINGS: Some people are very emotional and may or may not express it. How emotional are you? How deeply do you feel things? How passionate are you?* 1 (Lowest) 2 3 4 5 6 7 (Highest) PHYSICAL SENSATIONS: Some people attach a lot of value to sensory experiences such as sex, food, music, art, and other "sensory delights." Others are very much aware of their minor aches, pains, and discomforts. How "tuned into" your sensations are you?* 1 (Lowest) 2 3 4 5 6 7 (Highest) MENTAL IMAGES: How much fantasy or daydreaming do you engage in? This is separate from thinking or planning. This is "thinking in pictures," visualizing real or imagined experiences, letting your mind roam. How much are you into imagery?* 1 (Lowest) 2 3 4 5 6 7 (Highest) THOUGHTS: Some people are very analytical and like to plan things. They like to reason things through. How much of a "thinker" and "planner" are you?* 1 (Lowest) 2 3 4 5 6 7 (Highest) BIOLOGICAL FACTORS: Are you healthy and health conscious? Do you avoid bad habits like smoking, too much alcohol, drinking a lot of coffee, overeating, etc.? Do you exercise regularly, get enough sleep, avoid junk foods, and generally take care of your body?* 1 (Lowest) 2 3 4 5 6 7 (Highest) Final Question!Are there any significant childhood (or other) memories or experiences not otherwise discussed above that you think your therapist should be aware of:* Yes No If yes, please explain:*CAPTCHA Δ
