PERSONAL HISTORY QUESTIONNAIRE
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1 PERSONAL HISTORY QUESTIONNAIRE Here are several pages of questions that we want you to answer about yourself. Please answer them to the best of your ability, as completely and honestly as you can. Completing this information now will save a great deal of time during your evaluation! Name Today=s date Mailing address Home phone Cell phone Work phone You may get help with this questionnaire if you need it, because we are interested in having complete and accurate information. Helped by Relationship Person to be notified in case of emergency: Name Phone Relationship Are you your own guardian? Y / N Does someone hold Power of Attorney for you? Y / N Name of guardian (or person with POA) Phone Name and address of family physician How did you learn of? Physician referral Friend or Family Member Web search Other What is your understanding of the reason for this examination? Do you have a disability or special need for which you require accommodation for this examination, such as severe visual or hearing problems, severe pain, problems with mobility, severe fatigue, etc.? Please describe:
2 GENERAL INFORMATION: Date of Birth Age Gender M / F Hand dominance First language Marital status Spouse/partner=s first name How long married/together? Children (#, ages) Place of birth Where did you spend most of your growing-up years? If you immigrated to Canada, what year was that? Why did you move to Canada? FAMILY HISTORY: Father: Present age Yrs of Education Occupation Hand he writes with (If deceased, age at death Cause of death ) Mother: Present age Yrs of Education Occupation Hand she writes with (If deceased, age at death Cause of death ) Siblings: first names and present ages Was there much conflict, abuse or dysfunction in your family when you were growing up? Please describe briefly Have close relatives (parent, sibling, your children) had any of the following chronic or serious medical problems? If so, indicate who: Cancer Lung disease / asthma Dementia Alcohol/drug abuse Diabetes Multiple sclerosis Anxiety Intellectual disability Thyroid problems Epilepsy / Seizures Depression Learning disability Heart problems Stroke Bipolar disorder ADD / ADHD High blood pressure Huntington s / other genetic disorder Schizophrenia Other EDUCATION HISTORY: Circle highest year of elementary/secondary school you completed: College: Masters Doctoral Professional Any trouble learning to read? Write? Do math? Receive special services? If yes, what for? Repeat any grades? If yes, which ones? Year left or graduated High School College/university attended Major Grade average Year left/graduated College/university attended Major Grade average Year left/graduated Additional education (e.g., technical school, specialized training, etc.) 2
3 WORK HISTORY: What is your occupation or usual type of work? For how many years? Present or most recent job: Title/job description Employer Dates worked there Reason for leaving (if not working now) Previous job: Title/job description Employer Dates worked there Reason for leaving (if not working now) Previous job: Title/job description Employer Dates worked there Reason for leaving (if not working now) Previous job: Title/job description Employer Dates worked there Reason for leaving (if not working now) Did/do you generally enjoy your work? Yes No Did/do you get positive job evaluations? Any particular problems at work? Yes No Please specify If you are not working now, give reason MILITARY SERVICE: Branch of military #Years served Dates: Highest rank See combat? Type of discharge Job in military Any problems? LEGAL HISTORY: Ever been arrested? When? What for? Have you ever been convicted of a felony? Are you currently involved in any lawsuits or legal actions? Ever serve time in jail or prison? Specify MEDICAL / MENTAL HEALTH HISTORY: Check any of the following that you have had. Please also give date or approximate age when it began or was diagnosed. Cancer Lung disease / asthma Parkinson s disease Schizophrenia Diabetes Sleep apnea Depression Learning disabilities Thyroid problems Multiple Sclerosis Anxiety ADD/ADHD Heart problems Epilepsy / seizures PTSD Abuse or severe neglect High blood pressure Dementia / MCI Bipolar Disorder Other 3
4 Head injury with loss of consciousness. Please describe (date, circumstances) Drug/alcohol abuse. Please describe Stroke, brain tumor, or brain infection (meningitis or encephalitis). Please give approximate date and general details Major surgery for Allergies: Treatment for emotional problems. What were you treated for? What kind of treatment? (please circle all that apply) Medications / Counseling / Hospitalization If hospitalized, please give details (when, where) Name of current psychiatrist and/or therapist Other medical or psychiatric issues Give name(s) of doctors seen in last 6 months and any involved agencies: Doctor=s name Specialty Doctor=s name Specialty Doctor=s name Specialty Agency Agency Please list all medications that you currently take (prescribed or over-the-counter): Medicine For (illness) [Write on back if necessary to list all medications] CURRENT SUBSTANCE USE: Number of cigarettes you smoke / day How many years have you smoked? If you quit smoking, when was that? Typical amount of alcohol you now consume in one day / week / year: What type? Any recreational drugs used now? What type? 4
5 ACTIVITIES OF DAILY LIVING: Have you experienced difficulties in any of the following areas of functioning in the last 6 months? If yes, check: Eating Daily hygiene Getting dressed Bathing Speech/Communication Socializing Cleaning Cooking Shopping Handling money/finances Reading Writing Using phone Using computer Using equipment/tools Walking Going up or down stairs Details: Do you drive a motor vehicle? Any problems driving? Explain LIFESTYLE FACTORS: What types of activities do you participate in for fun? Do you participate in any volunteer or community activities? Have you had to change or cut back the activities you enjoy doing? Yes / No If so, why? Do you regularly attend social functions? Yes / No Do you regularly spend time with friends? Yes / No Do you exercise regularly? Yes / No If yes, what do you do? If no, why not? How would you rate the nutritional quality of your diet, on a scale of 1 to 5, where 1 is the worst and 5 is the best? ADDITIONAL INFORMATION: Please give any other information about yourself that you think is important for us to know. 5
6 PROBLEM CHECKLIST Please carefully review the following list of problems. If any of them apply to you currently or in the last month, please check the level of severity (mild, moderate or severe). If there are no problems, leave the boxes blank. SLEEP Mild Moderate Severe Problem Problem Problem Comments Falling asleep Restless, poor sleep Nightmares Getting up in morning ENERGY / FATIGUE Too much energy Low energy/stamina APPETITE / WEIGHT Not eating enough Eating too much Weight (over/under) Poor food choices BOWELS / BLADDER Accidents/@soiling@ Diarrhea/constipation PAIN Frequent or severe pain Where? Headaches Joint pain Back pain Other HEARING Hard of hearing Overly sensitive VISION Poor acuity/blurriness Light sensitivity BALANCE/COORDINATION Using tools/utensils Dizziness/vertigo Balance Walking SEXUAL Dysfunction/pain Problematic behaviors 6
7 Mild Moderate Severe Problem Problem Problem Comments MEMORY Recalling old information Recalling new information Recalling names Remembering dates, events, appointments Remembering what I read Losing things ATTENTION / CONCENTRATION Staying focused on task Distractible Needing repetition Completing tasks/projects SPEECH / LANGUAGE Thinking of words, names Expressing thoughts Understanding conversation Pronunciation EXECUTIVE Difficulty organizing belongings Difficulty organizing tasks Can=t make decisions Procrastinate Difficulty with changes Problems getting started on tasks SCHOOLING [current students] Reading Writing Math Taking notes Attendance Taking tests Larger projects (such as reports, term papers) WORK Poor evaluations Conflict with supervisors Conflict with co-workers Productivity, speed Stress at or about work SOCIAL Verbal conflict with others Physically aggressive Choices of friends Gullible, easily influenced Shy Isolated, lonely 7
8 Mild Moderate Severe Problem Problem Problem Comments Impulsive, disinhibited Making/keeping friends Marriage/partnership EMOTIONAL Anger/irritability Depression Anxiety, worry Fears, phobias Feelings of inferiority Moody, ups & downs Suicidal thoughts Hallucinations Unusual thoughts (delusions, paranoia) UNUSUAL OR REPETITIVE BEHAVIOURS Odd mannerisms or habits Tics Obsessive or compulsive behaviours Hoarding Unusual movements (e.g., rocking, hand flapping) COMMENTS: Please describe any other problems you experience that are not listed above. THANK YOU!! Please bring this completed questionnaire with you to your appointment at North Shore Neuropsychology / North Shore Memory Clinic. If you have any questions, please call us at or us at info@northshoreneuropsych.com. 8
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1811 B Green Circle Valdosta, GA Do you have any problems at this time?
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Restore Counseling Center 630 E Southlake Blvd, Ste 127, Southlake, Tx
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Nebraska Bariatric Medicine 8207 Northwoods Dr., Suite 101 Lincoln, NE MEDICAL HISTORY
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CHILD / ADOLESCENT HISTORY
CHILD / ADOLESCENT HISTORY PERSON FILLING OUT THIS FORM DATE PATIENT NAME: DATE OF BIRTH AGE APPOINTMENT DATE: HOME TELEPHONE: MOTHER NAME: _ OCCUPATION WK TEL FATHER NAME: OCCUPATION _ WK TEL YOU ARE
PSYCHOLOGICAL EVALUTAION QUESTIONNAIRE
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Address: City/State/Zip: Home Phone: Cell: Pager: Work Phone: Employer/School: Emergency Contact: Phone:
Rock Landing Psychological Group Adult Client Information Please Print Name: Relationship Status: Single Married Domestic Partner Separated Divorced Widowed Date of Birth: Female Male Ethnicity: Address:
SOAR Referral. RETURN OR FAX: ATTENTION Worcester County Core Service Agency at Referring Agency: Referral by: Contact information:
SOAR Referral Client Name: Date: Gender: M F Race: Social Security Number: DOB: Does client have a birth certificate and valid ID? YES NO If yes please send copies along with referral. If no would client
Name: Gender: male female Age: Date of birth: / / Preferred phone: cell home work other. Alternate phone: cell home work other.
Casey Alexander Paleos, MD NEW CLIENT INTAKE FORM 775 Park Avenue, Suite 200-2 Huntington, NY 11743 tel 631-629-5887 Date: / / BASIC INFORMATION Name: Gender: male female Age: Date of birth: / / Preferred
Child s name: Nickname: Date of Birth: / / Sex: Male Female SSN: Today s date: / / Parent s Name #1: Home phone: ( ) Cell: ( )
Please fill out the entire form, answering the questions as they pertain to your child or teen. Leave blank any that are unclear or that you want additional clarification on. Thank you. General Information:
Unity Memory Clinic. Please fill out this form and bring it to your appointment. Name of patient: Last First MI. Male Female Date of Birth:
Unity Memory Clinic Patient information Name of patient: Please fill out this form and bring it to your appointment Last First MI Male Female Date of Birth: Caregiver/Contact Person Information Name of
Joan B. Jablow, APMHNP 45 Byram Lake Road Mt. Kisco, New York (914)
Joan B. Jablow, APMHNP 45 Byram Lake Road Mt. Kisco, New York 10549 jablownp@optimum.net (914) 241-1246 Personal Adult (18+) Client s name: Date: Gender: F M Date of birth: Age: Address: City: State: Zip:
PATIENT INFORMATION Name: Date of Birth: Last First MI Phone number: Relationship to patient
Alzheimer s and Memory Care Program PATIENT INFORMATION Name: Date of Birth: Last First MI Phone number: CAREGIVER/CONTACT PERSON INFORMATION Name of person completing form if other than patient: Phone
Adult Service Application
Adult Service Application Client # Client Name: Date: _ Are you your own legal guardian? Yes No If no, who is your legal guardian? Former name/maiden name: _ Sex: Male Female Sexual Orientation: _ SSN:
CHECKLIST OF CONCERNS AND HISTORY FORM
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Biographical History Form Child/Adolescent
Biographical History Form Child/Adolescent First Name: Middle Name: Last Name: Address: Child s Age: Child s DOB: / / Male Female Today s Date: / / Mother/Guardian: Cell #: Home#: Father/Guardian: Cell
Child s Information (Please print) Name Birth Date Age Home Address City State Zip Code
The following questions are asked so that we can best understand your child. Please fill out this questionnaire before the child is evaluated. Please read the questions carefully and answer them as fully
HD CLINIC MEDICAL HISTORY FORM
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