Background Questionnaire
Thank you for taking the time to fill out this questionnaire. This information helps me to better understand you asa complete person. With that knowledge, the test findings can be more accurately interpreted.
Demographic Data
Name:______Date:______
Date of birth: ______Age: ______Gender: Male Female
Home Address:______
Employer/School: ______
Occupation: ______
Education level: ______
Phone: Home:______Work:______
Cell: ______E-Mail:______
Can I leave a personal message? ______
Current Marital/Relationship Status ______
If divorced or separated, when did this occur? ______
If widowed, when did this occur? ______
Do you have any children? Yes No
If so, please list their names, genders, and ages below:
______
______
If divorced with children, what is the custody agreement? ______
______
List all people living in your household including Name, Age, and Relationship:
______
______
______
Recent family stressors (deaths, births, moves, job loss, etc.):
______
Dominant language spoken in the home: ______
Other languages spoken in the home: ______
Name of primary care physician: ______
Name of other significant health care providers: ______
Who referred you?______
Are you seeking assistance with a court case? Yes No
Have you been or are you currently involved in any legal proceedings or pursuits?
Yes No
If so, please explain: ______
______
Family of Origin History
Father’s Name: ______Age: ______
Occupation:______Deceased? Yes No
Mother’s Name: ______Age: ______
Occupation: ______Deceased? Yes No
Marital status of parents: ______
If separated or divorced, how old were you when the separation occurred? ______
If divorced, was the divorce amicable? ______
If divorced, what was the custody arrangement? ______
______
List all brothers, sisters or other significant people living outside the household:
______
Have you ever been abused (emotionally, physically, or sexually)? Yes No
If yes, please explain: ______
______
______
______
How were you disciplined as a child? ______
How would you describe your childhood and your relationship with the members of your family of origin? ______
______
______
______
Presenting Problem:
Briefly describe your current difficulties and/or concerns:______
______
How long has this problem been of concern to you?______
______
When was this problem first noticed?______
______
In your opinion, what is the major cause of these difficulties? ______
Have you ever received evaluation or treatment for the current problem or for similar
problems? Yes No
If yes, when and with whom? ______
______
Have you been in therapy at any time? Yes No
If yes, when and with whom? ______
______
Is abuse of alcohol, illegal drugs, or prescription drugs an issue for you? Yes No
If yes, please explain: ______
______
Are you being treated for a medical illness? Yes No
If yes, for what condition are you being treated? ______
______
Are you on any medications at this time? Yes No
If yes, please fill out the chart below:
Medication: Dosage: Reason for medicine:
______
______
Social and Behavioral Checklist:
Place a check next to any behavior or problem that you recall having as a child:
Difficulty with hearing
Difficulty with vision
Difficulty with coordination
Difficulty with balance
Difficulty making friends
Difficulty keeping friends
Preferred to be alone
Did not get along well with brothers/sisters
Fought verbally with adults
Bullying
Mood swings
Aggressive behavior (describe)
Withdrawn behavior (describe)
Shyness
Clinging to others
Low energy
More interested in things (objects) than people
Engaged in behavior that could be dangerous to self or others (describe)
Broke objects deliberately
Lied frequently (describe)
Stole (describe)
Self injury
Running away
Low self-esteem
Blaming others for troubles
Is argumentative
Did not show feelings
Frequent crying spells
Had unusual or special fears, habits, or mannerisms (describe)
Bed wetting
Sleepwalking
Temper problems
Sleeping problems
Rocking or head banging
Poor appetite
Eating disorder
Poor bowel control
Hyperactivity
Distractibility
Disorganization
Clumsiness
Irritability
Overly talkative
Forgetfulness
Daydreaming
Worrying too much
Impulsivity
Risky behavior
Excessive guilt
Learning disabilities
Repetitive behavior (e.g. Hand flapping, wheel spinning)
Tics or twitches
Constantly seeking attention
Nervousness and anxiety
Overly suspicious of other people
Feeling sad or unhappy often
Suicidal thoughts
Poor attention span
Poor memory
Setting fires
Fearful of new situations
Used illegal drugs (describe)
Used alcohol
Sexually provocative behavior
Anxiety when separated from parents
Anxiety about going to school
Compulsion about cleanliness – wanting to wash or feeling dirty all the time
Other Problems (describe)
Academic History:
How were your grades? (Please indicate below):
Elementary: ______
Middle School: ______
High School: ______
College: ______
What subjects were you good in? ______
What subjects were difficult for you? ______
Were you in any special education classes? Yes No
If yes, what type of class? ______
Were you held back in a grade? Yes No
If yes, what grade and why? ______
Were you in honors or advanced classes? ______
Did you receive special tutoring or therapy in school? Yes No
If yes, please describe: ______
Did you ever receive special tutoring or therapy outside of school? Yes No
If yes, please describe: ______
Did you like school? Yes No
Birth History:
Are you adopted? Yes No
If so, please list what you know about your birth parents: ______
Were there any problems during your mother’s pregnancy with you? Yes No
If yes, please describe:______
______
Were you exposed to any problematic substances in utero (e.g. medications,
drugs, alcohol, X-rays, chemicals, etc)? Yes No
Details: ______
Infancy:
The following questions relate to your early childhood. You may not know the answers to many of these questions. Please provide whatever information you do have regarding your early development.
Were there any birth defects, illnesses, or complications during your mother’s pregnancy with you? Yes No
If yes, please describe:______
Did you grow normally? Yes No
If no, please describe: ______
Speech/Language Development:
Age youspoke your first word ______put 2-3 words together ______
Speech delays/problems (e.g. Stuttering, delay in speech)?______
Oral-motor problems (e.g. Late drooling, poor sucking, poor chewing)? ______
Was speech/language therapy ever necessary? ______
Were you slow to learn the alphabet? ______name colors? ______count? ______
Were there any other special problems in your growth and development during the first few years? Yes No
If yes, Please describe:______
______
Medical History:
Place a check next to any illness of conditions that you have experienced. When you check an item, please note the approximate time when you had the illness orcondition:
Head Injuries
Meningitis
Encephalitis
High fever
Convulsions
Injuries to head
Seizures
Broken bones
Hearing problems
Ear infections (tubes needed?)
Sleeping problems
Fainting spells
Loss of consciousness
Paralysis
Dizziness
Frequent headaches
Difficulty concentrating
Memory problems
Extreme tiredness
Rheumatic fever
Epilepsy
Tuberculosis
Bone or joint disease
Gonorrhea or syphilis
Anemia
Jaundice
Hepatitis
Diabetes
Cancer
High blood pressure
Heart disease
Thyroid Condition
HIV
AIDS
Family Medical and Psychological History:
Place a check next to any illness or conditions that any member of your familyhas experienced. When you check an item, please note the family member’s relationship to you.
Academic problem orLearning Disability
Alcoholism
Cancer
Depression
Developmental problem orMental Retardation
Diabetes
Drug problem
Emotional problem
Epilepsy
Autism or Aspergers
Anxiety
Personality Disorder
Bipolar Disorder or Manic Depression
ADD/ADHD
Suicide attempt
Other problem
Activities:
What do you enjoy doing for fun?______
______
Please give me a brief and general idea of your weekly schedule:
MonTuesWedThursFriSat Sun
______
______
______
Do you have any special areas of talent?______
______
What are three positive traits that you see in yourself?______
______
What are three negative traits that you see in yourself?______
Please Sign Below:
I consent to psychological testing or therapy with Dr. Miller, and understand the limits of confidentiality associated with this. I accept and understand the financial responsibility outlined in the Psychologist-Patient Agreement provided to me.
______Date: ______
Signature
______Date: ______
Signature
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