Adult History Form

Today's Date

MM slash DD slash YYYY

Basic Information

Name*

First Last

Email*

Age*

Date of Birth*

MM slash DD slash YYYY

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Best Phone Number*

Occupation*

Marital Status*

Handedness*

Ethnicity or Race*

Primary Language*

Who referred you to my office?*

What is your major concern that led you to seek help?*

What other concerns do you have?*

Have you been diagnosed with any psychiatric conditions? If so, what are they?*

Do you currently have a psychiatrist?*

Name*

Do you currently have a therapist?*

Name*

Medical History

Primary Care Provider

For what conditions are you currently being treated, including those being treated by medical providers other than your primary care provider?*

Please list all current medications, dosages and duration of use:

Medication

Dosage

Approximate Duration of Use

Medication

Dosage

Approximate Duration of Use

Medication

Dosage

Approximate Duration of Use

Please list any previous psychiatric medications that you have taken and discontinued:*

Please list all surgeries with approximate dates or ages:*

Please list all hospitalizations with approximate dates or ages:*

What other medical or physical problems have you had? Please mark all that apply.*

Head injury/concussion

Poor circulation

Fibromyalgia

Respiratory problems

Headaches/migraine

Gastrointestinal problems

Chronic pain

Memory changes

Hearing/speech disorders

Diabetes/Hypoglycemia

Seizure(s)

Loss of consciousness

Thyroid problems

Heart problems

Arthritis/Joint pain

Hypertension

Neurological problems (numbness, tingling, weakness)

Have you ever seen a neurologist for any reason? If yes, please explain:*

Do you have any allergies? If yes, please list them:*

On average, how many hours of sleep do you get per night?*

Please check any of the following sleep problems you have now or have experienced in the past:*

Difficulty falling asleep

Difficulty waking in the morning

Frequent waking

Not rested after sleep

Nightmares

Sleep apnea

Sleeping too much

Teeth grinding

Do you exercise regularly?*

Do you drink alcohol?*

How many occasions of drinking alcohol per week?*

How many drinks, on average, per occasion of drinking?*

Are you or have you have been concerned about your drinking?*

Has a friend of family member ever told you that they are concerned about your drinking?*

Do you use illegal drugs?*

Please describe:*

Developmental History

Were there any problems/complications during pregnancy or delivery? If so, describe:*

Were you adopted? If yes, at what age?*

Were there any delays in your development of language? If so, describe:*

Were there any delays in your development of motor skills, such as sitting up independently, crawling and walking? If so, describe:*

As a child, did you experience physical, sexual or emotional abuse?*

As a child, did you experience any significant stressors, such as serious illness, frequent moving, family drug or alcohol abuse?*

Please check any of the following that were a problem for you during your school years:*

Reading difficulties, including decoding or reading comprehension

Math difficulties

Writing difficulties, including poor spelling and handwriting

Poor visual-spatial skills (drawing, copying figures)

Poor grades

Behavior problems

Peer problems

Highest educational level completed?*

Current employement?*

Previous employment history?*

Behavioral Issues

Please indicated if you have or have had difficulty with any of the following areas:*

Inattention/distractibility

Hyperactivity/impulsivity

Depression

Poor anger management

Compulsive behavior

Agitation

Panic attacks

Phobias

Muscle/Verbal Tics

Obsessive thinking

Inability to read social cues

Poor self-esteem

Have you ever been violent or destructive? Have you ever hurt an animal or person intentionally, or threatened to harm or kill someone?*

Have you ever been arrested or had legal problems?*

Have you ever considered suicide or attempted suicide? If yes, please describe?*

Please list family psychiatric history. Are you aware of any of your biological relatives having been diagnosed with a psychiatric or mental health disorder (such as depression, anxiety, Bipolar Disorder, PTSD, schizophrenia), an attention disorder (such as ADHD), a learning disorder (such as dyslexia, dysgraphia or dyscalculia), or a developmental disorder (such as Autism Spectrum Disorder), a personality disorder (Borderline Personality Disorder, Narcissistic Personality Disorder)? If you strongly suspect someone in your family suffered from a disorder that was diagnosed, please include that here:*

Family/Social Issues

Who is living in your home?*

Have you recently had any disruptions in your life, including family crisis, conflicts, grief or other loss, financial problems, job difficulties, etc? If yes, please explain:*

Have you ever experienced trauma or abuse (e.g., physical, sexual, emotional/verbal)?*

Do you have a social support network?*

What are your strengths?*

Goals

If you are seeking evaluation, what questions do you have that you would like to have answered through the evaluation process? What are your goals for the evaluation?*

If you are seeking therapy, what are your goals for therapy?*

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Basic Information

Medical History

Developmental History

Behavioral Issues

Family/Social Issues

Goals

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