Professional Documents
Culture Documents
Adolescent Questionnaire
Please answer the following questions accurately. Its okay to pass on some questions, but it really helps me to get
to know you and understand what might be bothering you, if you try to answer as completely and accurately as
possible.
Name: _________________________________________
Birthdate: ________________________
2
____ Irritability, crabby behavior
_________________________________________________________________________
____ Sexual problems, worries ___________________________________________________________________________
____ Abuse (verbal, physical, sexual) ______________________________________________________________________
____ guilty, shameful feelings ___________________________________________________________________________
____ Hallucinations (seeing or hearing things that arent there)__________________________________________________
____ Spending habits __________________________________________________________________________________
____ Gambling/computer games _________________________________________________________________________
____ Shy, social problems ______________________________________________________________________________
____ Frequent lying ___________________________________________________________________________________
____ Physical problems, pain, illness _____________________________________________________________________
____ Feeling lonely ___________________________________________________________________________________
____ Other symptoms, worries, problems __________________________________________________________________
3
Do you get along with your teachers? ______________________________________________________
What subject do you like least? ________________________________ Most? _____________________
Are you involved in after school sports/activities? If so what are they: _____________________________
___________________________________________________________________________________
Sexual History:
Do you have a boyfriend/girlfriend? ________________________________________________________
Are you sexually active? ________________________________________________________________
Do you use birth control? _______________________________________________________________
Have you ever had a sexually transmitted disease (STD)? ________________________________________
Have you ever been raped or had sexual contact you didnt want? (please explain) ____________________
____________________________________________________________________________________
Nutritional and Exercise History:
What is your weight? _______________________ What is your height?__________________________
How do you feel about your weight and height? _______________________________________________
What do you eat during the day? Breakfast, lunch, dinner, and snacks: _____________________________
____________________________________________________________________________________
____________________________________________________________________________________
Do you exercise or play sports? ___________________________________________________________
How much time do you spend watching TV or playing computer games? ____________________________
Social/Friendships:
How many close friends do you have? ______________________________________________________
Do you feel you can talk to your friends about your worries, problems? _____________________________
Do you ever get teased or bullied? (please explain) _____________________________________________
____________________________________________________________________________________
What do you like to do with your friends? ___________________________________________________
____________________________________________________________________________________
Do you feel you have enough friends and are you happy with your social activities? (please explain) _______
____________________________________________________________________________________
Spirituality/religion:
Do you attend church? _________________________________________________________________
Do you feel you are spiritual or religious? ___________________________________________________
Do you believe in a life after death? _______________________________________________________
Do you find comfort and support in a church community or in your spiritual beliefs? (please explain) ______
____________________________________________________________________________________
Please explain why you are seeking counseling/therapy? (ie. worries, problems with mood, parents made you
come, relationship problems, suicidal thoughts, other) __________________________________________
Thank you for completing this questionnaire!