BACKGROUND HISTORY QUESTIONNAIRE
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- Ethel Sharp
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1 BACKGROUND HISTORY QUESTIONNAIRE Name: Sex M F Address: Home Number: Work Number: Cell Number: SSN: Name and Address of Employer: Date of Birth: Age: Ethnicity: Referred By: Referral Question or Presenting Problem: Primary Physician: Other Specialists (include name and specialty): MEDICAL HISTORY: Previous hospitalizations, surgeries or accidents (describe when occurred, age, length of stay): Serious illnesses: Medical problems currently affecting you: Family history of serious illnesses: Previous loss of consciousness related to head injury or concussion - If yes, describe circumstances, when occurred, medical treatment: History of seizures: Other neurological disorders (stroke, hemorrhage, etc.): Family history of neurological illness If yes, describe:
2 Current medications (name and dosage): Vision difficulties: Hearing difficulties: Previous tests performed: (please include year performed and results) EEG: Head CT scan: Brain MRI: Psychological Testing: Neuropsychological Testing: Other medical findings or diagnoses: PSYCHIATRIC HISTORY: History of emotional disorder/psychiatric treatment (diagnosis if known, age diagnosed, treating physician, medications prescribed): When did you first seek psychiatric treatment? For what problems did you seek treatment? Was treatment helpful? Current psychiatrist: (name, when treatment started, focus of treatment) Current medications prescribed (name, dosage): Medications taken in the past (name, dosage): Current therapist: (name, when treatment started, focus of treatment) Inpatient hospitalizations (hospital, age, nature and duration of treatment): Previous suicide attempts (age, injuries): Family history of psychiatric treatment or illness: 2
3 SUBSTANCE USE HISTORY: Previous/current use of: Nicotine (age began using, how long using, current usage): Alcohol (age began using, how long using, current usage): Ever experience blackouts or withdrawal symptoms? Recreational drugs (specify drug, age began using, how long using, current usage): Drug of choice, if any: Formal treatment for drug or alcohol abuse (detoxification, rehabilitation, AA or NA). If yes, describe: PERSONAL HISTORY: Place of Birth: Where Raised: Native Language: Handedness: Developmental milestones (e.g. walking, talking) attained early/late/within normal limits: Education including high school (include name of institution, degree obtained, year of graduation): School Problems (repeated grades, failed classes, special education, tutoring): If any, please describe: Ever diagnosed with a learning disability or Attention Deficit/Hyperactivity Disorder? If yes, when and by whom: Behavioral Problems as a child (if yes, describe): _ Current Occupation (include job title, company name): How long at current job? Last Job: Previous Work History: _ 3
4 Current Marital Status: S M D W If married, separated, divorced or widowed, please note when: List those individuals living with you (the patient) at the present time: Name Sex Age Relationship Education Occupation Health How long at current residence? List immediate family members not living with you (children, siblings, parents, etc.): Name Sex Age Relationship Education Occupation Health CURRENT COMPLAINTS Physical symptoms & changes: Weakness: Hearing defects: Numbness: Problems with taste: Muscle tics/twitches: Problems with smell: Clumsiness: Bladder/bowel control: Headache: Change in appetite/weight: Pain: Change in sleep pattern: Dizziness: Seizures: Nausea: Fainting spells: Visual defects: Other: Any Recent changes in: Appetite / Weight Sleep Energy levels Sexual interest / libido Behavioral concerns: Unusual fears: High activity level Slowed response: Sexual difficulties Destructiveness: Aggressiveness 4
5 Irritability: Restlessness Excessive sadness: Nightmares Self-destructive: Easily frustrated Stubbornness: Eating problems Sleep problems: Mood swings Suicidal thoughts Withdrawn Isolated Problems in driving: Intellectual Concerns: Difficulty planning or organizing Difficulty in completing activities Difficulty adapting to changes (rigid) Inability to concentrate Easily distracted Impulsive Difficulty learning or remembering Difficulty with comprehension Difficulty with expression Gets lost easily Difficulty with writing Difficulty with reading Difficulty with math Periods of confusion or disorientation Slowed thought processes Changes in mood or personality Change in the way you get along with others Change in social activities Are symptoms staying the same or getting worse? What is your best guess as to why the symptoms are happening? Has daily living at home, work or in social situations been affected by your symptoms? If yes, describe: What if anything, has helped your symptoms? 5
6 Please add any additional comments: 6
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