Lydia Byhardt Bollinger, MSW * Licensed Clinical Social Worker
* * 971-409-5613
Adult History Form
Name Age Birth date
Occupation Employer
Marital StatusName of Spouse/Partner
How Long Have Both of You Been Together? Religion
Last Medical Examination:Reason:
Primary Medical Provider:
Current health concerns:
Current Medications / Reason/DosageIf you take more medications than space allows, please continue on the back of the page.
Have You Ever Been Hospitalized for a Physical Illness? NoYes - Describe:
Personal or Family History of:
Involvement with law:
Anyone in family use: DrugsTobacco Alcohol
Personal or Family history of:
Mental health concerns
Medical concerns
Abuse (physical, sexual, verbal)
Serious loss (such as death in family, frequent moves, divorce, physical separation from important person, change in health)
Trauma (Such as car accident, physical injury, physical/emotional/sexual abuse)
Describe:
Have you ever been diagnosed or hospitalized for Depression, Anxiety Disorder, ADHD, Schizophrenia, etc? No Yes - Describe:
Rate Any of the Following That May Apply to You:
0-None 1-Mild 2-Moderate 3-Severe
0 - none1-Mild2-Moderate / Headache / 0 - none1-Mild2-Moderate / Inferiority Feelings / 0 - none1-Mild2-Moderate / Shy With People0 - none1-Mild2-Moderate / Dizziness / 0 - none1-Mild2-Moderate / Feel Tense / 0 - none1-Mild2-Moderate / Can’t Make Friends
0 - none1-Mild2-Moderate / Fainting Spells / 0 - none1-Mild2-Moderate / Feel Panicky / 0 - none1-Mild2-Moderate / Afraid Of People
0 - none1-Mild2-Moderate / No Appetite / 0 - none1-Mild2-Moderate / Fears and Phobias / 0 - none1-Mild2-Moderate / Unable To Have A Good Time
0 - none1-Mild2-Moderate / Stomach Trouble / 0 - none1-Mild2-Moderate / Obsessions / 0 - none1-Mild2-Moderate / Can’t Make Decisions
0 - none1-Mild2-Moderate / Bowel Disturbances / 0 - none1-Mild2-Moderate / Depressed / 0 - none1-Mild2-Moderate / Always Worried
0 - none1-Mild2-Moderate / Always Tired / 0 - none1-Mild2-Moderate / Self-harm/injury / 0 - none1-Mild2-Moderate / Homicidal ideas
0 - none1-Mild2-Moderate / Always Sleepy / 0 - none1-Mild2-Moderate / Suicidal Ideas / 0 - none1-Mild2-Moderate / Can’t Keep A Job
0 - none1-Mild2-Moderate / Unable To Relax / 0 - none1-Mild2-Moderate / Take Tranquilizers / 0 - none1-Mild2-Moderate / Co-worker conflict
0 - none1-Mild2-Moderate / Insomnia / 0 - none1-Mild2-Moderate / Substance Abuse / 0 - none1-Mild2-Moderate / Over-Ambitious
0 - none1-Mild2-Moderate / Recurrent Dreams / 0 - none1-Mild2-Moderate / Eating disorder / 0 - none1-Mild2-Moderate / Financial Problems
0 - none1-Mild2-Moderate / Nightmares / 0 - none1-Mild2-Moderate / Appetite Problem / 0 - none1-Mild2-Moderate / Other Job Problems
0 - none1-Mild2-Moderate / Hallucinations / 0 - none1-Mild2-Moderate / Aggression / 0 - none1-Mild2-Moderate / Gambling
0 - none1-Mild2-Moderate / Physical Pain / 0 - none1-Mild2-Moderate / Allergy / 0 - none1-Mild2-Moderate / Sexual Problems
0 - none1-Mild2-Moderate / Memory loss / 0 - none1-Mild2-Moderate / Asthma / Risky behaviors (ie: promiscuity, speeding, stealing, other ____)
0 - none1-Mild2-Moderate / Home Conflict / 0 - none1-Mild2-Moderate / Don’t Like Weekends/ Vacations
0 - none1-Mild2-Moderate / Other:
History of
Counseling: IndividualCouplesFamily Outpatient Group Counseling
Day TreatmentInpatientPsychiatric ER
When and Number of Sessions:
Was it a positive experience? What did or did not work for you?
Current Stresses:
Anything else you want me to know?
What do you wish to Achieve with Coaching/Therapy?