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Name
Are you Married?
Prior Marriage?
The purpose of this questionnaire is to help determine possible entryways for evil spirits. There are 30 ancestors in your history that could have passed on generational line strongholds. Please give any information that the Holy Spirit brings to your attention: Examples would be involvement with the occult, sexual perversion, alcoholism, depression or mental disorders, lots of divorce, adultery, anger, criminal activity, births out of wedlock, involvement in groups such as Masonry, Eastern Star, Rainbow Girls, Oddfellows and Rebecca Lodge etc

Note: It is not necessary to go into great detail with any of the responses. Ask Holy Spirit to show you any area of concern.

Have you participated in premarital sex?
Are your parent's divorced?
Have you been exposed to pornography? If Yes, how old were you? _______

Please answer the following questions as they apply to your life: ( Yes or No)

Do you have Homosexual tendencies?
Have you participated in college fraternities or sororities?
Do you have feelings of guilt and shame?
Do you experience feelings of hopelessness or dispair?
Do you experience feelings of fatigue without medical reason?
Have you had an Abortion?
Do you have difficulty forgiving?
Do you have bitterness, anger, or unforgiveness?
Do you experience feelings of self hate?
Have you suffered from self harm?
Do you experience feelings of rejection?
Are there any objects in your home or in your possession that relate to ungodliness or cults, this would include new age religions, such as books about eastern deities, crystals, heavy metal music, Native American/African artifacts, Items connected with other religions or rituals, Wiccan or other occult items, etc.?
Have you ever "felt" a presence in the room home recently?
Do you hear voices?
Do you have nightmares?
Have you been diagnosed by a doctor as having: (list any diagnosis, diabetes, asthma hypertension, etc.)?
Do you experience pain in your body with no medical explanation?
Do you have difficulty trusting others?
Have you had someone close to you die?
Have you had someone close to you die?
Do you feel like you have any eating disorders?
Do you have any sleep disorders
When attending Church or other ministries do you have "foul" thoughts, jealousies or other mental harassment?
Do you have difficulty retaining God's Word?
Do you have difficulty reading God's Word?
Do you get migraine headaches?
Do you have any addictions?
Have you ever been diagnosed with a learning disability i.e. (A.D.D.)?
Do you have a fear of death?
Have you ever had suicidal thoughts?
Has there been a period of time in your life when you were angry with God?
Do you have a fear of losing your mind?
Do you suffer from anxiety or panic attacks?
Do you feel incredible loneliness?
Are you plagued with doubt and unbelief?
Do you have feelings of inferiority?
Do you have thoughts of inadequacy?
Do you have obsessive thoughts?
Do you have blasphemous thoughts?
Do you have compulsive thoughts?
Do you daydream?
Do you have lustful thoughts?
Are you a perfectionist?
Are things seemingly always out of order?
Do you feel the need to be in control?
Are you rebellious?

Below are a few symptoms of demonic attack, please check any symptom that applies to you:

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