Multimodal Life History Inventory
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 as accurately as you can. You will
facilitate your therapeutic program. You are requested to answer these routine questions in
your own time instead of using up your actual consulting time (please feel free to use extra
sheets if you need additional answer space).

It is understandable that you might be concerned about what happens to the information
about you because much or all of this information is highly personal.

*Case records are strictly confidential*

Please allow for 20 minutes or more to complete this inventory.
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Additional Information
Second edition. 1991
First edition. 1980. published as the Multimodal Life History Questionnaire
Copyright 1991 by Arnold A. Lazarus and Clifford N. Lazarus
All rights reserved Printed in the United States of America.
No part of this inventory may be reproduced by any means without the written permission of the publishers.

Research Press
2612 North Mattis Avenue
Champaign. Illinois 61821
General Information
Please complete preliminary section below.
Full Name:
Address:
Age & Gender:
Date of Birth:
MM
/
DD
/
YYYY
Weight:
If your weight fluctuates, please describe how much:
Do you have a family physician?
Clear selection
If you do have a family physician, please provide the name and telephone number:
Marital Status (check one):
Clear selection
Do you live in:
Clear selection
With whom do you live? (check all that apply):
What sort of work are you doing now?
Does your present work satisfy you?
Clear selection
If "no" to previous question, please explain:
What kinds of jobs have you held in the past?
Have you been in therapy before or received any professional assistance for your problems?
Clear selection
Have you ever been hospitalized for psychological/psychiatric problems?
Clear selection
If "yes" to previous, when and where?
Have you ever attempted suicide?
Clear selection
Does any member of your family suffer from an "emotional" or "mental disorder"?
Clear selection
Has any relative attempted or committed suicide?
Clear selection
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