SUBJECT: CLIENT QUESTIONAIRE FILE: UFO2247 Answering the questions on the folling forms is strictly voluntary. However it's completetion helps the investigator(s) to get a general picture of the person that they are dealing with. The questions are specifically designed to provide clues to the nature and type of encounter that you experienced. All information on these forms remains confidential in accordance with the Federal Privacy Act of 1977, and cannot be released without the specific permission the UFINET and/or the Investigator. ====================================================================== DEMOGRAPHIC Name__________________________________________________________________ Last First Middle Address____________________Sex:_________________Race:________________ Date of Birth________________Martial Status__________________________ PRESENTING SITUATION A. Referral Source:___________________________________________________ B. History of Current Situation. What happened and what is going on in your life at present__________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ (If there is not enough room, continue on a separate piece of paper) FAMILY HISTORY Members of Present Household: History of Name Relationship Age emotional Problems? ____________ _________________ __ ________________________ ____________ _________________ ___ ________________________ ____________ _________________ ___ ________________________ ____________ _________________ ___ ________________________ Date of Present Marriage_________ If previously married, How many times?_______ How was marriage terminated?_________________________________________ Children by previous marriage/relationships who are not currently living with you. History of Name Age Place of Residence Emotional Problems? _________ ___ ________________________ ________________________ _________ ___ ________________________ ________________________ _________ ___ ________________________ ________________________ Any family history of Suicide?______ If so, who?_______________ Any family history of psychiatric?______ if so, who?_____________ Any family history of substance abuse?______ if so, who?___________ SOCIAL HISTORY Education: Last grade completed_________ G.E.D_________ Employment: Present Occupation______________ Full time?__________ Present Employer?_____________________________ How Long?____________ MEDICAL HISTORY: Any treatment by your physician during the past five year? If so for what? ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Hospitalization required for the above? If so, where and when? ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Any physical disabilities?____________________________________________ Any Allergies?________________________________________________________ Medications currently in use?_________________________________________ Have you used Alcohol or drugs in the past?____ If so, which?_________ ______________________________________________________________________ Have you received treatment for Alcohol or drug use in the Past?______ if so, where and when?________________________________________________ ______________________________________________________________________ LEGAL HISTORY: Ever arrested since age 18?________________ Charge Date Disposition _______________________ _______ ____________________________ _______________________ _______ ____________________________ _______________________ _______ ____________________________ Current Legal Status_________________ Probation Officer_______________ Lawyer__________________________Address_______________________________ ______________________________________________________________________ Any Extenuating circumstances concerning the above that you feel we should be aware of?: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ GENERAL HEALTH HISTORY: Have you experienced or been diagnost as having problems with the following. (Please circle appropiate item) RINGING IN EARS KIDNEY DISORDERS HIGH BLOOD PRESSURE BLADDER ULCERS HEMROIDS INTESTINES EYES HEART DISEASE HEARING STOMACH SINUS/NASAL LIVER BLURRED VISION THROAT FEMALE DISORDERS LUNGS Describe problems with items circled: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Name___________________________________________Date__________________ On this questionaire are groups of statements. Please read each group of statements carefully. Then pick out the one statement in each group which best describes the way you have been feeling the PAST WEEK, INCLUDING TODAY! Circle the number beside the statement you picked. If several statements in the group seem to apply equally well, circle each one. Be sure to read all of these statements before making your choice. ====================================================================== 1. 0 I do not feel sad. 1 I feel sad. 2 I am sad all of the time and I can't snap out of it. 3 I am so sad or unhappy that I can't stand it. 2. 0 I am not particularly discouraged about the future. 1 I feel discouraged about the future. 2 I feel I have nothing to look forward to. 3 I feel the future is hopeless and things cannot improve. 3. 0 I do not feel like a failure. 1 I feel I have failed more than the average person. 2 As I look back on my life, all I can see is a lot of failure. 3 I feel I am a complete failure as a person. 4. 0 I get as much satisfaction out of things as I used to. 1 I don't enjoy things the way I used to. 2 I don't get real satisfaction out of things anymore. 3 I am dissatisfied or bored with everything. 5. 0 I don't feel particularly guilty. 1 I feel guilty a good part of the time. 2 I feel quite guilty most of the time. 3 I feel guilty all of the time. 6. 0 I don't feel I am being punished. 1 I feel I may be punished. 2 I expect to be punished. 3 I feel I am being punished. 7. 0 I don't feel disappointed in myself. 1 I am disappointed in myself. 2 I am disgusted with myself. 3 I hate myself. 8. 0 I don't feel I am any worst than anybody else. 1 I am critical of myself for my weaknesses or mistakes. 2 I blame myself all the time for my faults. 3 I blame myself for everything bad that happens. 9. 0 I don't have any thoughts of killing myself. 1 I have thoughts of killing myself, but I would not carry them out. 2 I would like to kill myself. 3 I would kill myself if I had the chance. 10. 0 I don't cry anymore than usual. 1 I cry more now than I used to. 2 I cry all the time now. 3 I used to be able to cry, but now I can't cry even though I want to. 11. 0 I am no more irritated now than I ever am. 1 I get annoyed or irritated more esily than I used to. 2 I feel irritated all the time now. 3 I don't get irritated at all by the things that used to irritate me. 12. 0 I have not lost interest in other people. 1 I am less interested in other people than I used to be. 2 I have lost most of my interest in other people. 3 I have lost all my interest in other people. 13. 0 I make decisions about as well as I ever could. 1 I put off making decisions more than I used to. 2 I have greater difficulty in making decisions than before. 3 I can't make decisions at all anymore. 14. 0 I don't feel I look any worse than I used to. 1 I am worried that I am looking old or unattractive. 2 I feel that there are permanent chnages in my appearance that make me look unattractive. 3 I believe that I look ugly. 15. 0 I can work about as well as before. 1 It takes an extra effort to get started at doing something. 2 I have to push myself very hard to do anything. 3 I can't do any work at all. 16. 0 I can sleep as well as usual. 1 I don't sleep as well as I used to. 2 I wake up 1-2 hours earlier than usual and find it hard to get back to sleep. 3 I wake up several hours earlier than I used to and cannot get back to sleep. 17. 0 I don't get more tired than usual. 1 I get tired more easily than I used to. 2 I get tired from doing almost anything. 3 I am to tired to do anything. 18. 0 My appetite is no worst than usual. 1 My appetite is not as good as it used to be. 2 My appetite is much worse now. 3 I have no appetite at all anymore. 19. 0 I haven't lost much weight, if any lately. I am purposely trying to loose weight by eating less 1 I have lost more than 5 pounds. yes_______no_____ 2 I have lost more than 10 pounds. 3 I have lost more than 15 pounds. 20. 0 I am no more worried about my health than usual. 1 I am worried about physical problems such as aches and pains; or upset stomach; or constipation. 2 I am very worried about physical problems and it's hard to think of anything else. 3 I am so worried about my physical problems, that I cannot think about anything else. 21. 0 I have not noticed any recent change in my interest in sex. 1 I am less interested in sex than I used to be. 2 I am much less interested in sex now. 3 I have lost interest in sex completely. Please describe in your own words, with as much detail as possible the circumstances that lead you to believe that you have been the subject of an Alien contact. (If you wish, you may send an audio-cassette describing the circumstances and why you feel the way that you do. Please include the names and addresses of any pyschologist that you have seen, and forward any tapes or reports that he/she might have). PLEASE INCLUDE ANY PHOTOGRAPHS/DRAWINGS THAT YOU MIGHT HAVE IN ORDER TO HELP US WITH THE INVESTIGATION. (Use the rest of this page and the other side. Use more paper if needed). ********************************************** * THE U.F.O. BBS - http://www.ufobbs.com/ufo * **********************************************