General Information    
Last Name First Name Middle Name SEX
Address City State Zip
Phone   Email
Place of Birth Height Weight
Previous Polygraph Examination : Explain
List all current medical/physical conditions :
Any Current Discomfort : Describe
Are you pregnant :
Have you eaten in the last 24 hours :
Time you went to bed :
Time you got up :
How did you sleep :
Major injury/surgery within the last 6 months : List
Do you currently have heart problems :
Do you have any communicable diseases now :
Have high/low blood pressure :
Do you have seizures :
Do You Have Trouble hearing :
Currently having back pain :
Alcohol in last 24 hours :
list all medications that are currently prescribed to you :
Ever seen apsychologis to rpsychiatrist :
Any illegal drugs consumed in last 24/48 hours :
Please list the drugs taken, how much and when :
Ever been a patient in a mental hospital :
Have you ever been diagnosed with or treated for: Depression :
Have you ever been diagnosed with or treated for: Schizophrenia :
Bipolar Disorder :
Panic/Stress Disorder :
Obsessive Compulsive Disorder :
Alcohol Dependence :
Drug Addiction :
Any Eating Disorder :
Any form of Personality Disorder :
Posttraumatic Stress Disorder:
Phobias :