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West Bradenton Biblical Counseling

Gender

Marriage And Family Information

(Significant Other, - *S.O. is used.)

Today, WBBC recognizes that it is not uncommon for couples to decide not to marry.  For this reason, the term S.O. is provided. However for simplification please complete form using the provided Spouses information.  You may skip this if so desired.
 

Religious Information

Your Religious Background
Spouse's Religious Background
Personality Information
Have you ever had Psychothearapy or Counselin before?
Have you ever been treated for an addiction?
How Do You See Yourself - Check All That Apply
Health Information

APPROXIMATELY HOW MANY HOURS OF SLEEP DO YOU GET EACH NIGHT?  ________

DISCRIBE RECENT CHANGES IN SLEEP HABITS:  ______________________________

RATE YOUR HEALTH: 

RECENT CHANGES (EXPLAIN) 

RECENT CHANGES IN WEIGHT (EXPLAIN)

LIST ALL IMORTANT PRESENT PAST ILLNESSES, INJURIES, OR HANDICAPS:

DOES THE ABOVE LIMIT YOU IN ANY WAY?  

DATE OF LAST MEDICAL EXAMINATION:  _________________________

PHYSICIANS NAME: ________________________________

DO YOU DRINK ALCHOLIC BEVERAGES?  NO _______  YES ______  WHAT (Other Ways of Coping?)  __________________ 

Medical Information

ARE YOU CURRENTLY TAKING MEDICATION?  NO _____ YES ______  WHAT? ____________

LIST MEDICATIONS BELOW AND INCLUE DOSAGE AND PURPOSE

HAVE YOU USED DRUGS OR PERSCRIPTION MEDICATIONS  Yes ______  No ____  WHEN  _____?

HAVE YOU EVER BEEN ARRESTED?  Yes ______  No ______  ,  Please describe briefly the circumstances and the charge?

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