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? Yes NoAs 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? Yes NoName 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 MM slash DD slash YYYY Medical HistoryFamily doctorPhone MM slash DD slash YYYY Have you ever been in the hospital for medical problems? Yes NoIf YesHospital Name, City, and stateDatesReason For HospitalizationHospital Name, City, and stateDatesReason For HospitalizationHospital Name, City, and stateDatesDo you have any serious or chronic physical or medical condition (diabetes, etc.)? Yes NoIf Yes, please explainAre you taking any prescribed/non-prescribed medications? Yes NoIf Yes, please list belowReactionTreatmentAllergyReactionTreatmentAllergyReactionTreatmentHave you ever been injured in any accidents or falls? Yes NoIf Yes, please list belowInjuryAgeIncidentInjuryAgeIncidentInjuryAgeHave you suffered any complications of illnesses or accidents (high fever, convulsions, coma, etc)? Yes NoIf Yes, please explainDo you now, or have you ever in the past, used alcohol or other drugs on a regular basis? Yes NoIf Yes, please list belowHow often?How much in each episode?Type of drugHow often?How much in each episode?Type of drugHow often?How much in each episode?Do you now, or in the past, smoked cigarettes/cigars/pipes on a regular basis? Yes NoIf Yes, please list belowHow often?How many years?Type of tobaccoHow often?How many years?Have you experienced difficulty with any of the following? (Please check all that apply.)Headaches Yes Current N/ASeizures Yes Current N/ANumbness/tingling in extremities Yes Current N/ADifficulty maintaining balance Yes Current N/AFainting or black out spells Yes Current N/ARinging in ears Yes Current N/ADifficulty with hearing Yes Current N/ADifficulty with vision Yes Current N/AShortness of breath Yes Current N/AHigh blood pressure Yes Current N/ATrouble with swallowing Yes Current N/ADiarrhea, chronic Yes Current N/AWeight gain or loss in the past year Yes Current N/ALoss of appetite Yes Current N/APreoccupation with weight gain or loss Yes Current N/AEating problems Yes Current N/AItching of skin Yes Current N/ASkin rash Yes Current N/AHyperactivity Yes Current N/ACrying spells Yes Current N/AFeeling angry often Yes Current N/AMood swings Yes Current N/ANervousness Yes Current N/AProblems/ difficulty with memory Yes Current N/AProblem with thinking clearly Yes Current N/AChronic fatigue or weakness Yes Current N/AProblems with attention/concentration Yes Current N/ADepression and anxiety Yes Current N/ASudden behavior or personality change Yes Current N/ASleeping problems Yes Current N/AImpulsive; act without thinking Yes Current N/AProblems with sexual behavior Yes Current N/APhysical assault/abuse Yes Current N/AProblems with sexual behavior Yes Current N/ASexual assault / abuse Yes Current N/AAnxiety / panic episodes Yes Current N/AFinancial problems Yes Current N/AOccupational problems Yes Current N/ALearning problems Yes Current N/AFamily/relationship difficulties Yes Current N/ASocial relationship problems Yes Current N/AUnusual experiences Yes Current N/ADisturbing thoughts Yes Current N/ASuicide attempts Yes Current N/ASuicidal thoughts Yes Current N/AProblems with the law Yes Current N/APregnancy Information (if applicable)Were there any physical or emotional difficulties during pregnancy with your children or during your mother’s pregnancy with you? Yes NoIf Yes, please explainWere you or were any of your children premature? Yes NoIf 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? Yes NoIf 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? Yes NoIf Yes, please explainHas anyone in the family (including grandparents) had a substance abuse problem? Yes NoIf Yes, please explainList individuals that live in your home.Family HistoryFatherAgeState of HealthOccupationMotherAgeState of HealthOccupationSpouseAgeState of HealthOccupationBrothersAgeState of HealthOccupationNameAgeState of HealthOccupationSistersAgeState of HealthOccupationNameAgeState of HealthOccupationSonAgeState of HealthOccupationNameAgeOccupationNameAgeState of HealthOccupationDaughterAgeState of HealthOccupationAgeState of HealthOccupationNameAgeState of HealthOccupationWho 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* MM slash DD slash YYYY CLICK HERE TO PRINT THIS FORM BEFORE SUBMITTING
