Have you ever received counselling or sought advice from a psychologist, psychiatrist, counsellor and/or doctor? Yes No
Is your physical ability restricted in any way? Yes No
Do you take any medications or prescription drugs? If yes, state how often and for which condition below? Yes No
Have you ever been treated for alcoholism/drug dependency? Yes No
Are you currently taking any medication (including contraceptive pill)? Yes No
Is there any history of nervous or emotional problems, depression or abuse (sexual, emotional or physical) in
your family background? Yes No
Are you on any medical treatment that will require medical attention during your time as an au pair? Yes No
Do you wear braces? Yes No
Do you have any limitations that restricts you from lifting a child (i.e. recent surgery/back problems etc)? Yes No