Troy University

BACKGROUND QUESTIONNAIRE: ADULT

Client Name / Today’s Date
School/Occupation / Date of Birth
Sex / c Male / c Female / Age

What is your primary language ?

Troy University

Presenting Problem

Describe your current difficulties:

What help, if any, do you think is needed?

When did you first notice the problem?

How long has this problem been of concern to you?

How did this problem come to your attention?

Who brought this problem to your attention?

Who has tried to help with this problem? c Family c School c Doctor c Friends c No One c Other

What has been done to help the problem?

Have you been tested previously? c No c Yes Explain

What evaluation or treatment have you already
received for the current or similar problems?

Who provided the treatment and when was it?

Who referred you this clinic?

What seems to help the problem?

What seems to make the problem worse?

Troy University

Medical History

Please mark any illness or condition that you have had. When you check an item, also note the approximate date (or ages) of the illness.

Date/Age / Date/Age / Date/Age
c Measles / c Dizziness / c Hospitalizations
c Diphtheria / c Mumps / c High Blood Pressure
c Chicken Pox / c Eczema or hives / c Whooping cough
c Meningitis / c Asthma / c Jaundice/hepatitis
c Scarlet fever / c Paralysis / c Bleeding Problems
c Tuberculosis / c Convulsions / c Memory problems
c Cancer / c Rheumatic fever / c Bone joint disease
c Epilepsy / c High fever / c Difficulty concentrating
c Allergy / c Broken bones / c Heart disease
c Hay fever / c Injuries to head / c Heart condition/murmur
c Diabetes / c Operations / c Dental problems
c Fainting Spells / c Visual Problems / c Stitches
c Anemia / c Suicide Attempt / c Loss of consciousness
c Seizures / c German Measles / c Poisoning
c Extreme tiredness or weakness / c Frequent or severe headaches / c Ear problems, disease, infection or impairment

Troy University

Describe Medical Events here:


Family Medical History

Mark illnesses or conditions that any member of the immediate family has had.

When you mark an item, please note the person’s relationship to the client.

Relationship / Relationship
c Alcoholism/drug use / c Nervous/psychological problem
c Cancer / c Diabetes
c Depression / c Heart trouble
c Suicide attempt / c Learning difficulties
c Hyperactivity / c Seizures/epilepsy
c Behavior Problems / c Special Ed./Chapt. I program
c Attention Problems / c Speech/language problems
c Other / c Other

Educational History

I have completed the following degrees (check all that apply)

c High School c Associate’s c Undergraduate c Graduate

c I have not completed any of the above degrees.

How did you do in school?

Have you met your career goals in life? c No c Yes

If not, why not?

Did you receive special education services? c No c Yes

If Yes, What was your disability? ______

Educational History (for current college students only)

I am a (check one)

c College Undergraduate c c Junior c Senior c Grad/Professional Student

What is your current major?

Have you changed your major since beginning college? c No c Yes

If Yes, how many majors have you declared?

What is your current grade point average (GPA)?

Did you attend a 2-year college prior to enrolling at your current institution? c No c Yes

Did you attend any other 4-year colleges? c No c Yes