Adult Information Form

ADULT INFORMATION FORM

Date: ______Patient Name: ______DOB:______

CURRENT PROBLEMS:

Please describe your current difficulties and reason for seeking services______

______

______

PLEASE CIRCLE ANY CURRENT DIFFICULTIES:

CONFIDENTIAL MEDICAL RECORD TURN PAGE OVER

NAME______

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Sadness
Short Attention Span
Worry
Verbal
Aggression
Nightmares
Oppositional Behavior
Avoidant Behaviors
Excessive Sleeping / Irritability
Compulsive Behavior
Fatigue
Physical
Aggression
Flashbacks
Sexual Acting
Out
Suicidal/Homicidal Thoughts
Lack of
Motivation / Anger
Obsessive Thinking
Guilt
Frequent
Crying
Hopelessness
Weight
Gain
Memory Impairment
Insomnia / Anxiety
Social Withdrawal
Mood Swings
Explosive Behavior
Social Anxiety
Weight
Loss
Delayed Onset Sleep
Self-Injury / Panic Attacks
Relationship Problems
Lying
Substance Abuse
Hyperactivity
Easily Embarrassed
Impulsive Behavior
Suspiciousness

Other ______

PLEASE CIRCLE ANY RECENT OR CHRONIC STRESSORS:

Divorce
Financial Change
Health Problems in Family
Unemployment / Marriage
Break Up of Relationship
Inadequate Financial Resources
Arrest / Family Conflict
Marital Problems
Death of Family Member or Friend
Victim of a Crime / Remarriage
Conflict with Peers
Inadequate Housing
Inadequate Social Support / Birth of Child
Employment Problems
Health Problems
Other ______
______

DEVELOPMENTAL HISTORY/CHILDHOOD MEDICAL INFORMATION

Any problems with pregnancy and birth __Yes __No If yes, describe ______

______

Developmental Delays __Yes __No If yes, describe ______

______

Childhood illnesses/disorders (include dates and/or age)______

CURRENT MEDICAL INFORMATION

Primary Care Physician______Specialists______

Current Illnesses/Conditions______

______

Allergies __Yes __No If yes, list ______

Current Medications ______

______

Height _____Weight______Weight Change __Yes __No If yes, describe______

______

Sleep Impairment __ Yes __No If yes, describe______

Surgeries __Yes __No If yes, list ______

Head Injuries __Yes __No If yes, describe ______

__ without loss of consciousness __ with loss of consciousness

Seizures __ Yes __No If yes, describe ______

Other Developmental and/or Medical Information

______

MENTAL HEALTH HISTORY:

Current and/or Past Providers______

______

Current and/or Past Diagnoses______

Inpatient Treatment __Yes __No If yes, when and where ______

Was past treatment helpful __Yes __ No Why______

______

Current Psychotropic Medications & Dosage Information __ Yes __No

If yes, list ______

Past Psychotropic Medications __Yes __No If yes, list ______

Past Suicide Attempts __ Yes __ No History of Suicidal Ideations __ Yes __ No

If yes, describe ______

FAMILY INFORMATION:

Mother______Educational Level______Occupation ______Employer ______

Father______Educational Level______

Occupation______Employer ______

Parents are ___Married ___Separated ___ Divorced/Year______

___Mother Remarried ___ Father Remarried

Siblings (Name/Age)______

Half/Step Siblings (Name/Age) ______

Raised by ______

Describe family relationships (past and current) ______

______

Family History of

Substance Abuse __Yes __No If yes, describe ______

Mental Illness __Yes __No If yes, describe ______

Suicide __Yes __No If yes, describe ______Violence __Yes __No If yes, describe ______

History of Childhood Abuse

__Physical Abuse __Yes __No If yes, describe______

__Sexual Abuse __Yes __No If yes, describe______

__Emotional/Verbal Abuse __Yes __No If yes, describe ______

__Abandonment/Neglect __Yes __No Witness of Abuse? __ Yes __ No

Removed from home __Yes __No If yes, describe ______

Perpetrator of Abuse? __Yes __No If yes, describe______

______

Other Family Information

______

EDUCATIONAL HISTORY:

Educational Level______

Special Education Services While in School __Yes __No If yes, services were based on what disability ______

Behavioral problems __Yes __ No If yes, describe ______Repeated grades __ Yes __No If yes, what grade/s ______

Suspensions/Expulsions __Yes __No If yes, describe______

Performance/Achievements______Attitude toward School______

Strengths/Weaknesses ______

Extra-Curricular Activities ______

SOCIAL HISTORY:

Describe peer relationships during childhood______

Describe current social relationships______

Relationship with Authority __Oppositional __Compliant __Neutral __ Overly Compliant

Current Social support networks __Family __Friends __Community Organizations

Hobbies/Interests______

Difficulty getting along with others? __ Yes __ No If yes, describe______

______

OCCUPATIONAL HISTORY:

__Employed FT __Employed PT __Unemployed __Retired __Disabled

Place of Employment ______Position ______

Special Training______

Describe Job Satisfaction ______

Describe Job Performance ______

Previous Employment ______

MILITARY HISTORY:

Branch of Service______Duty Status______Length of Service______

Discharge Type __honorable __dishonorable __medical __other than honorable

MARITAL/RELATIONSHIPS:

__Married __Single __ Widowed __Separated __ Divorced __ Long term relationship

Describe current relationship______

Please describe previous marriages/significant relationships______

______Children (include ages) ______

Custody Issues ______

Problems in Current and Past Relationships __Yes __No If yes, describe ______

______

SUBSTANCE USE HISTORY:

Nicotine Use __Yes __No If yes, type/s __Cigarettes __Snuff __Tobacco

Amount of Use ______Duration of Use ______

Alcohol Use __Yes __No If yes, frequency and amount of use ______

______

Drug Use __Yes __No If yes, drugs used ______

Past Drug Use __Yes __No If yes, drugs used______

Frequency of Use ______

Substance Abuse Treatment __Yes __No If yes, when and where ______

History of community or social difficulties due to substance use __Yes __No

If yes, describe______

Health Related Problems __Yes __No If yes, describe ______

______

LEGAL HISTORY:

Pending charges __Yes __No If yes, describe ______

______

Past Arrests __Yes __No If yes, describe ______Convictions __Yes __No If yes, describe ______

Jail/Prison __Yes __No If yes, describe ______

Probation/Parole Officer ______

Out of Home Placements During Childhood __ Yes __No If yes, describe______

______

Name of person completing form: ______

CONFIDENTIAL MEDICAL RECORD TURN PAGE OVER

NAME______

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