This Original Assessment Sheet is done as the beginning action of Dianetics. It is done in a formal Dianetic auditing session in an auditing room with the pc duly signed up, and in session.

The auditor assigned to audit the preclear does the assessment. It is included as part of the preclear’s auditing time as it is valuable data collection on the preclear’s case, done with the preclear on the meter.

The purpose of this form is to provide essential data regarding the preclear to the C/S, the D of P and the auditor, and to better acquaint the auditor with the preclear at the onset of auditing.

The assessment is done with the preclear on the meter.

The preclear is given the R-Factor that you will simply be asking him for essential data about himself for the purpose given above.

The auditor notes down the data as the pc gives it. He does not take up the pc’s answers to the questions, except, when necessary, to make sure the question is answered and the auditor has the facts straight. TA at start and end of the assessment is noted, along with any TA action during the assessment. Needle reactions to the questions are noted when the question is given plus any needle reaction that occurs during the pc’s reply.

The data should be written plainly and neatly on the assessment sheet so that it is readable, as the information is wanted. Auditor does not delay or hold up the pc giving answers, however, while he completes admin.

When completed, the Original Assessment Sheet is kept in the preclear’s folder. A note is made on the Summary Sheet of pc’s folder that the Original Assessment Sheet has been done.

TA Position at Start of Assessment: ________

1. Is mother living? ________________ E-Meter Reaction ____________

2. Date of Death: ________________ E-Meter Reaction ____________

3. Pc’s statement of relationship with mother: _____________________________ E-Meter Reaction ____________

4. Is father living? ________________ E-Meter Reaction ____________

5. Date of Death: ________________ E-Meter Reaction ____________

6. Pc’s statement of relationship with father: _____________________________ E-Meter Reaction ____________

7. List brothers, sisters, and other relatives of the pc, date of death of any and E-Meter reaction:

8. Where and with whom do you live? _______________________ E-Meter Reaction _______________

9. Are you currently associated with anyone who is antagonistic to mental or spiritual treatment or Scientology?

On questions 10 through 17 if the answer is “yes” find out who and E-Meter reaction.

10. Is anyone actively objecting to your getting treatment? _______________________

11. Has anyone insisted you get treatment? _______________________

12. Has anyone ever objected to your getting treatment? _______________________

13. Has anyone encouraged you to get treatment? _______________________

14. Has anyone ever objected to you getting better? _______________________

15. Has anyone ever assisted you in self-betterment? _______________________

16. Does anyone not like you the way you are? _______________________

17. Has anyone tried to make you change or be different? _______________________

1. Married ______ Single ______ No. of times Divorced ________________ E-Meter Reaction __________

2. Pc’s statement of relationship with spouse: _______________________ E-Meter Reaction __________

3. List any marital difficulties pc presently has: _______________________ E-Meter Reaction __________

4. If divorced, list reasons for divorce and pc’s emotional feeling about divorce: _______________________ E-Meter Reaction __________

5. List children, date of death of any child and E-Meter reaction:

State the level of schooling pc has had, university education, or professional training: _____________________ E-Meter Reaction ___________

State main jobs pc has held:

(NOTE: LIST DRUGS, MEDICINE OR ALCOHOL TAKEN THIS LIFETIME ONLY.)

1. Are you taking any drugs currently?

Have you ever taken drugs?

2. Are you taking any alcohol or alcoholic drink currently?

Have you ever taken alcohol or alcoholic drinks?

3. List any medicine currently or previously taken.

What severe losses have you had in life that influenced it?

What deaths have severely affected your life?

Are you upset with or cross about anything or anyone at this particular time?

1. Are you in any particular danger at this time?

2. Are there engrams that match this in the past?

(Note meter read.) ____________________

List any serious accidents pc has had, the date of such, any permanent physical damage, and E-Meter reaction.

List any serious illness pc has had giving date of each, any permanent-physical damage, and E-Meter reaction.

List any operation, the date of each and E-Meter reaction.

List any bad physical condition pc presently has and E-Meter reaction to such.

1. List any illnesses the pc currently has.

2. Do you have any recurring physical ailment? _____________ E-Meter Reaction _________

List any disability payment or pension received by the pc, what it is for, how much and for how long it has been received.

List any compulsions (things pc feels compelled to do), repressions (things pc must prevent himself from doing) and any fears of pc.

Are you trying to change something someone else doesn’t like?

List any crime committed by pc, prison sentence, if any.

List any interests and hobbies of pc.

1. List auditors, hours, and E-Meter reaction to any processing done.

2. List briefly processes run:

3. List goals attained from such processing:

4. List goals not attained from such processing:

1. Do you look on yourself as somebody else?

2. When you see pictures of the past do you see yourself from a distance?

1. What practices or treatments have you engaged upon in the past?

2. Are you continuing any of the above in the present?

You know of course that people sometimes get cross at the auditor or run away when they are withholding information from them and we don’t want you to do that.

Anything you tell me is confidential and is protected under ministerial confidence.

Is there anything we have missed or omitted while doing this assessment? (Carefully note any meter reads.)

Ask: “Is there anything you would care to tell me about this?”

State of needle at the end of the above _________________