Adult Information FormIDENTIFYING INFORMATIONPatient Name*Email* Date of Birth*Referred ByPhoneHighest Grade Level of Education CompletedDegree AchievedPRESENTING PROBLEMPlease describe the problems which have led you to seek treatment or evaluation.What do you believe to be the most important factor(s) causing the problem?When did you first notice these problems?Have there been any family changes (new baby, death, divorce, etc.) which may be related to these problems? Please explain:Have you ever been seen for counseling or therapy?YesNoAs an outpatient (clinic, private, etc.)Name of doctor or therapistPhoneAddressFor how long?DatesReason for treatmentName of doctor or therapistPhoneAddressFor how long?DatesReason for treatmentHave you been evaluated with psychological tests, e.g. intelligence testing or personality evaluation?YesNoName of doctor or therapistPhoneType of testingDatesAs an inpatient (in a hospital, residential treatment center, etc)Facility nameAddressFor how long?DatesReason for treatmentName of doctor or therapistPhoneSignature*Date Date Format: MM slash DD slash YYYY Medical HistoryFamily doctorPhone Date Format: MM slash DD slash YYYY Have you ever been in the hospital for medical problems?YesNoIf YesDo you have any serious or chronic physical or medical condition (diabetes, etc.)?YesNoIf Yes, please explainAre you taking any prescribed/non-prescribed medications?YesNoIf Yes, please list belowHave you ever been injured in any accidents or falls?YesNoIf Yes, please list belowHave you suffered any complications of illnesses or accidents (high fever, convulsions, coma, etc)?YesNoIf Yes, please explainDo you now, or have you ever in the past, used alcohol or other drugs on a regular basis?YesNoIf Yes, please list belowDo you now, or in the past, smoked cigarettes/cigars/pipes on a regular basis?YesNoIf Yes, please list belowHave you experienced difficulty with any of the following? (Please check all that apply.)HeadachesYesCurrentN/ASeizuresYesCurrentN/ANumbness/tingling in extremitiesYesCurrentN/ADifficulty maintaining balanceYesCurrentN/AFainting or black out spellsYesCurrentN/ARinging in earsYesCurrentN/ADifficulty with hearingYesCurrentN/ADifficulty with visionYesCurrentN/AShortness of breathYesCurrentN/AHigh blood pressureYesCurrentN/ATrouble with swallowingYesCurrentN/ADiarrhea, chronicYesCurrentN/AWeight gain or loss in the past yearYesCurrentN/ALoss of appetiteYesCurrentN/APreoccupation with weight gain or lossYesCurrentN/AEating problemsYesCurrentN/AItching of skinYesCurrentN/ASkin rashYesCurrentN/AHyperactivityYesCurrentN/ACrying spellsYesCurrentN/AFeeling angry oftenYesCurrentN/AMood swingsYesCurrentN/ANervousnessYesCurrentN/AProblems/ difficulty with memoryYesCurrentN/AProblem with thinking clearlyYesCurrentN/AChronic fatigue or weaknessYesCurrentN/AProblems with attention/concentrationYesCurrentN/ADepression and anxietyYesCurrentN/ASudden behavior or personality changeYesCurrentN/ASleeping problemsYesCurrentN/AImpulsive; act without thinkingYesCurrentN/AProblems with sexual behaviorYesCurrentN/APhysical assault/abuseYesCurrentN/AProblems with sexual behaviorYesCurrentN/ASexual assault / abuseYesCurrentN/AAnxiety / panic episodesYesCurrentN/AFinancial problemsYesCurrentN/AOccupational problemsYesCurrentN/ALearning problemsYesCurrentN/AFamily/relationship difficultiesYesCurrentN/ASocial relationship problemsYesCurrentN/AUnusual experiencesYesCurrentN/ADisturbing thoughtsYesCurrentN/ASuicide attemptsYesCurrentN/ASuicidal thoughtsYesCurrentN/AProblems with the lawYesCurrentN/APregnancy Information (if applicable)Were there any physical or emotional difficulties during pregnancy with your children or during your mother’s pregnancy with you?YesNoIf Yes, please explainWere you or were any of your children premature?YesNoIf premature, please give the number of weeks early.SelfChildrenWere there any of the following complaints? Mother taking medication or drugs? (Specify)Can choose one or multiple Long labor Forceps delivery Breech birth Eclampsia Cesarean SectionOtherWere there any immediate complications following delivery of your children or with you?YesNoIf Yes, please explainNumber of pregnanciesNumber of miscarriagesWeight of largest child at birthFamily InformationHas anyone in the family (including grandparents) been treated for a mental health problem?YesNoIf Yes, please explainHas anyone in the family (including grandparents) had a substance abuse problem?YesNoIf Yes, please explainList individuals that live in your home.Family HistoryFatherMotherSpouseBrothersSistersSonDaughterWho in your family has had:Cancer Father Mother Sister Brother Grandmother Grandfather Children OtherTuberculosis Father Mother Sister Brother Grandmother Grandfather Children OtherAllergies & Asthma Father Mother Sister Brother Grandmother Grandfather Children OtherStrokes Father Mother Sister Brother Grandmother Grandfather Children OtherNervous Breakdowns Father Mother Sister Brother Grandmother Grandfather Children OtherSuicide Father Mother Sister Brother Grandmother Grandfather Children OtherConvulsions/epilepsy Father Mother Sister Brother Grandmother Grandfather Children OtherHeadaches Father Mother Sister Brother Grandmother Grandfather Children OtherDiabetes Father Mother Sister Brother Grandmother Grandfather Children OtherArthritis Father Mother Sister Brother Grandmother Grandfather Children OtherHeart Attack Father Mother Sister Brother Grandmother Grandfather Children OtherHigh Blood Pressure Father Mother Sister Brother Grandmother Grandfather Children OtherKidney Stones Father Mother Sister Brother Grandmother Grandfather Children OtherUlcers Father Mother Sister Brother Grandmother Grandfather Children OtherOther Father Mother Sister Brother Grandmother Grandfather Children OtherI understand that this information will be used in my evaluation and will be included in my records.Signature*Date* Date Format: MM slash DD slash YYYY CLICK HERE TO PRINT THIS FORM BEFORE SUBMITTING
