ADULT QUESTIONNAIRE. What have you been told with regard to the problem?
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1 1 ADULT QUESTIONNAIRE Please complete this 2-sided questionnaire. Write N/A when a question is not applicable. Date: Full Name: Birth Date: Age: Sex: Home Address: Telephone: City: State: Zip Code: Name of your employer: Job title: Please state why you scheduled this appointment and what you hope to gain from working with us: REASON FOR REFERRAL Who referred you for evaluation/treatment? On a scale of 1 to 10 (1 being not at all a problem and 10 being a very severe problem), please rate the severity of your problem(s): When did you first notice the problem? What have you been told with regard to the problem? TREATMENT What kinds of things have you tried in order to take care of the problem? Have you seen other professionals? ( ) Yes ( ) No If yes, who, when, where, and to what result? MARRIAGE AND FAMILY Current marital status: ( ) Single ( ) Dating ( ) Engaged ( ) Married ( ) Domestic Partnership ( ) Separated ( ) Divorced ( ) Widowed Describe past significant relationships and their length: Full name of current spouse/significant other: Spouse/significant other s age: Spouse/significant other s birth date: / / Spouse/significant other s employer: Job title: Are there any problems in your relationship with your spouse/significant other? ( ) Yes ( ) No If yes, please describe/explain: What kinds of activities do you do just with your spouse/significant other? Do you have Children? ( ) Yes ( ) No CHILDREN Name of child Biological, Step, or Adopted Date of Birth School Level/Occupation Are there any problems in your relationship with your children? ( ) Yes ( ) No If yes, please describe/explain:
2 What kinds of activities do you do together with your children? What kinds of activities do you do as a family? FAMILY OF ORIGIN Please complete as applicable. Name Age Occupation/School Living or Deceased Mother Father Step-Mother Step-Father Siblings 2 Step-Siblings Are there any problems in your relationship with your mother? ( ) Yes ( ) No Are there any problems in your relationship with your father? ( ) Yes ( ) No Are there any problems in your relationship with your siblings? ( ) Yes ( ) No FAMILY BACKGROUND Has anyone in your family had any of the following: Yes No Relationship to Client Alcoholism Anxiety attacks Arrests Behavior problems as a child Depression Dropped out of school or failed a grade Drug abuse Eating disorder (anorexia/bulimia) Epilepsy Huntington s disease Attention Deficit Hyperactivity Disorder (ADHD) Learning disabilities Mental retardation Migraine headaches Narcolepsy (sleep attacks) Nervous breakdown Obsessions or compulsions Panic attacks/agoraphobia Psych. hospitalization Suicide Tics or Tourette s Disorder Other:
3 DEVELOPMENT Did you have any language difficulties such as stammer, stutter, strange sounds, or problems in understanding? ( ) Yes ( ) No If yes, please explain: Were there any changes in your primary caretakers during the first 3 years of life? ( ) Yes ( ) No If yes, how many times and please explain: Were you attached to any inanimate objects (e.g., blanket, teddy bear, etc.)? ( ) Yes ( ) No If yes, what object? From age to. Are you: ( ) Right-handed ( ) left-handed ( ) ambidextrous EDUCATION Last level of education completed: Are you currently in school? If so, for what degree? 3 PSYCHIATRIC HISTORY AND INFORMATION Have you ever been treated at an outpatient clinic or hospitalized for mental health problems or problems with relationships? ( ) Yes ( ) No If yes, please provide the following information: Name of Therapist Name of Clinic/Hospital Dates of Treatment Reason for Treatment Has your spouse/significant other, children, or any other family members or extended family members experienced mental health problems? ( ) Yes ( ) No Have you ever thought of committing suicide? ( ) Yes ( ) No If yes, please explain: Have you ever attempted to take your life? ( ) Yes ( ) No If yes, please explain: Have you had any thoughts about suicide recently? ( ) Yes ( ) No If yes, please explain: Please describe your mood over the last seven days. TESTING Has there been intellectual or psychological testing or testing for learning disabilities done in the past? ( ) Yes ( ) No If yes, please explain what testing was done, when it was done, where it was done, by whom it was done, and what the results of the testing were: SUBSTANCE ABUSE INFORMATION Have you ever been treated at an outpatient clinic or hospitalized for alcohol/drug abuse? ( ) Yes ( ) No If yes, please provide the following information: Name of Therapist Name of Clinic/Hospital Dates of Treatment
4 Has your spouse/significant other, children, or any other family members or extended family members experienced a drug abuse/addiction? ( ) Yes ( ) No 4 Please complete as applicable. Check if ever used Name of Chemical (Circle the applicable substance) Beer, Wine, Liquor Marijuana/Hashish Amphetamines, Speed, Uppers, Ritalin, Dexedrine, Meth, Crank, Ephedrine Cocaine, Crack, Rock Inhalants (e.g. glue, aerosols, Glade, etc.), LSD, PCP Mushrooms, Peyote Heroine Opium, Morphine, Codeine Methadone Pain Killers (e.g. Darvon, Midol) Non-barbiturates: Restoril, Unis, sleeping pills Barbiturates: Amytal, Luminol, Seconal, Nemputal, downers Anti-Anxiety Agents: Valium, Librium, Ativan Antipsychotic Agents: Mellaril, Risperidol Anti-Depressants, Designer drugs: Cat, Special K, Ecstasy Tobacco, chew Other: How much? How often? Duration Age of First Use Age of Last Use Have you ever experienced blackouts or memory loss? ( ) Yes ( ) No If yes, when? Do you feel alcohol or drugs cause problems for you? ( ) Yes ( ) No If yes, explain: Has your family, friends, or employer ever objected to your drinking or drug use? ( ) Yes ( ) No If yes, explain: Have you ever attempted to cut down or stop drinking or drug use for a period of time? ( ) Yes ( ) No If yes, explain: LEGAL Have you ever been arrested? ( ) Yes ( ) No If yes, please list below: Year Charge Sentence
5 5 MEDICAL HISTORY Please provide the following information regarding the medical professionals you see: Physician Name Physician s Address Date last seen by this physician Have you had any surgeries, hospital stays, or other serious illnesses? ( ) Yes ( ) No If yes, please provide the information below: Describe medical problem Name of hospital/clinic Date of event/stay/illness CURRENT MEDICAL INFORMATION Are your immunizations up-to-date? Do you have any hearing problems or problems with ear infections? Do you have any eye problems? Do you have any of the following: Dizziness Double vision Fainting spells Loss of consciousness (blackout) Memory problems Momentary lapses of consciousness Severe headaches Sleep disturbances Trance-like episodes Tremors Troubles walking Incoordination Other Do you have problems with: Bones Digestive tract Genito-urinary system Heart and blood vessels Hormone system Muscles Respiratory system Yes No Comments For women only: a. Age of menses onset? b. Are they regular? c. PMS? d. Age of menopause onset?
6 6 MEDICATIONS Are you allergic or sensitive to any medications? ( ) Yes ( ) No If yes, please list the name(s) of the medication(s): Have you received medications in the past for emotional, learning, or behavior problems? ( ) Yes ( ) No If yes, please complete the box below: Your Age Name of Medication How long? Are you taking medication(s) now? ( ) Yes ( ) No If yes, please complete the box below: Name of Medication Dose Is it helping? PERSONALITY For each of the pairs of opposites below, check the one choice which best describes how you USUALLY FEEL. ( ) Happy ( ) Sad ( ) Withdrawn ( ) Outgoing ( ) Controlled ( ) Impulsive ( ) Confident ( ) Unconfident ( ) Calm ( ) Nervous ( ) Hostile ( ) Friendly ( ) Patient ( ) Frustrated ( ) Independent ( ) Dependent ( ) Changing Moods ( ) Steady Moods ( ) Fearless ( ) Frightened ( ) Hyperactive ( ) Lethargic ( ) Interested ( ) Bored ( ) Violent emotions ( ) Even Temper ( ) Eats Well ( ) Problem eater ( ) No sense of humor ( ) Humorous LEISURE TIME Would you rather spend your spare time alone or with someone? Would you rather spend your time inside or outside? What would you most like to do during your spare time? Do you have a preference to socialize mostly: ( ) with men ( ) with women ( ) both the same? Are there any particular habits or behaviors that seem to get you in trouble with other people? Describe your strengths (with regard to abilities, behavior, etc.): What things present the greatest difficulty for you? Describe your favorite indoors activity: Describe your favorite outdoors activity: How do you get a long in groups?
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