PINE TREE CLINIC FOR COMPREHENSIVE MEDICINE
ROBERT ZIEVE, MD

INTAKE FORM, Part 2

Additional Family Information

Personal Information

Name:_______________________________________________
Age:__________________ Birth Date: ____________________ Time: ____________________
Place of Birth: _________________________________________________________________
Your Parents’ Date of Birth: Dad: _________________________ Mom: ___________________
Your Parents’ Wedding Date: _____________________________________________________
Gender: __________________________ Right or Left Handed: __________________________
How old were you when you became totally independent from your parents (independent from food, money and shelter). Be accurate: Month: __________________ Year: ________________
Marital Status History (complete history):
__________________________________________________________________________________________________________________________________________________________
No. of Children (age, date of birth): __________________________________________________________________________________________________________________________________________________________
Siblings and your rank in the family (including siblings stillborn or aborted): _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
No. of miscarriages you had: _____________________________________________________
No. of abortions (mother/you)_____________________________________________________
_____________________________________________________________________________
Completed Studies: ____________________________________________________________
Main Professional Activity: __________________________________________________________________________________________________________________________________________________________
What are you passionate about (one or two things)
_____________________________________________________________________________
What do you dislike the most? (one or two things) ____________________________________________________________________________
Main concern (reason why you are coming to this appointment). Please be as clear as possible: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Date: ________________________

LIFE TIME-LINE

Please write the major events of your life (dramatic events, trauma, shocks, fears, etc.), starting from “Now” backward to the “Birth.” Write everything meaningful that you can remember in our columns (Age, Date, Event, Feelings), as follows:

Example:

46 y 10 m Aug 10 2005 Car accident Fear, thoughts of death
40 y 02 m Nov 06 1999 Separation Despair, hopeless, unworthy
16 y 11 m Oct 20 1975 Parents’ divorce Powerless, sad, angry
13 y 02 m Nov 10 1972 Older brother died Sad, angry, rage, hurt

FINDINGS:

The greatest negative shock of your life (it could be the one that preceded your illness or another one).

Date/Age at the beginning of your illness:

Sudden sock or conclusion of a major event/situation, either positive or negative, which would have occurred or terminated in the months or the year hat preceded the beginning of the illness:

Fears and frights, fierce, intense or chronic (e.g.: drowning).

Very strong annoyances/ vexations with anger and sorrow (all 3 emotions at once, eg: a slap in the face).

Remorse, regrets.

Sudden traumatic event (e.g.: unexpected death of a loved one).

Heavy secret, never expressed to anyone:

Additional comments on certain important conflicts, if needed (10 to 20 lines, on a separate sheet).

Your Mother is Pregnant with you. What do you know about it?

What was happening in your parents’ lives: (accidents, loss of job, deaths, illnesses, earthquakes, floods, in-laws living with young couple, major elections, travel, etc.).

1. At the time of your conception:

2. During her pregnancy with you?

3. Up until your first birthday (1 year old)?

Describe Your Family Tree, as far as you can remember, going back, if possible, 3 or 4 generations on both your father’s and your mother’s sides of the family. Give any information you might have about any miscarriages or abortions, as well as about illnesses, causes of death, dates of birth and death, and particular characteristics of their lives. An example of a family tree is on the next page.

Family Tree Page

On a piece of paper, please draw your family tree. This consists of yourself, your siblings, your mother and your father in one row, your maternal and paternal grandparents in the row above with their children (your aunts and uncles) and your great maternal and paternal great-grandparents , one set for each set of grandparents, in the row above that, with your grandparents’ brothers and sisters. If you have your own children, please draw them into the row below yours.

Females are shown by a circle and males are shown by a square. If someone has died, please put an “X” in the center of the circle or square. The rows of siblings are ordered by age, oldest to youngest, from left to right.