Feil & Oppenheimer Psychological Services
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- Gwenda Lloyd
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1 Feil & Oppenheimer Psychological Services 260 Waseca Ave. Barrington, RI Fax: Adult Patient Questionnaire Name: Today's Date: Address: Home Phone: Work Phone: Cell Phone: Sex: Religion: Date of Birth: Age: Are you currently ( ) married ( ) widowed ( ) divorced ( ) separated ( ) have never been married? With whom do you live: Previous Marriages (if any) Your Family of Origin: Family Members Age Health Education/Work Father Mother Siblings In what kind of home do you live? ( ) private ( ) duplex ( ) apartment building ( ) other Is the dwelling ( ) owned or ( ) rented? MEDICAL HISTORY Have you been diagnosed with any behavioral, educational, medical, neurological, or psychiatric disorder, such as Attention Deficit Hyperactivity Disorder (ADHD), Learning Disorder (LD), or Anxiety and Mood Disorders? Yes No If Yes, please specify: Do you have any current medical conditions? Yes No If Yes, please list. Do you have any chronic or recurrent medical conditions? Yes No If Yes, please list.
2 Page 2 Any experience of abuse or trauma? PREVIOUS ILLNESSES: Place a check next to any illness or condition that you have had. Illness or Condition Illness or Condition Illness or Condition Anemia Epilepsy or seizures Loss of consciousness Arthritis (juvenile) Fainting Malnutrition Bleeding problems Fatigue (if chronic and severe) Measles Bone or joint disease Hay fever German measles Broken bones Head injury Meningitis Tuberculosis Cancer Headaches (frequent or severe) Mumps Chicken pox Heart disease Paralysis Diabetes Hepatitis Rheumatic fever Diphtheria High blood pressure (hypertension) Scarlet fever Eczema or hives High fever (greater than 104 degrees) Encephalitis Jaundice Whooping cough VISION: Date of most recent vision exam Do you have any vision problems? Yes No If Yes, is your vision corrected with (circle one): Eyeglasses Contact lenses Surgery HEARING: Date of most recent hearing exam Do you have any hearing problems? Yes No If Yes, has your hearing been treated? ALLERGIES: MEDICAL TREATMENT: Date of most recent medical exam Physician's name: Address: Phone: If you have ever undergone an operation or hospitalization, please list the problem below (usually an illness), your age, and the medical procedures that were implemented during the hospitalization. Problem Age Procedure If you have ever been treated with prescription medication other than for colds and minor infections, please list them below: Medication Age Reason Prescribed Current How often do you use alcohol, and what do you typically drink? List any recreation drugs you use and how often you use them. Have you used more alcohol or drugs than you intended this year? Yes No Have you ever felt the need to cut down on the amount you drink or use drugs? Yes No Do you smoke cigarettes? yes no If so, how frequently?
3 Page 3 Have you been diagnosed with any behavioral, educational, medical, neurological, or psychiatric disorder, such as Attention Deficit Hyperactivity Disorder (ADHD), Learning Disorder (LD), or Anxiety and Mood Disorders? Yes No If Yes, please specify: Do you have any current medical conditions? Yes No If Yes, please list. Do you have any chronic or recurrent medical conditions? Yes No If Yes, please list. Developmental History Were there any complications with your pregnancy or birth? yes no Childhood illnesses and accidents: Were you adopted? yes no If yes, when? Did you live anyone other than your parents while growing up? yes no Anything else we should know about your health and medical care? FAMILY MEDICAL HISTORY Have any other family members shown similar problems or challenges? Yes No If Yes, who? Place a check next to any illness or condition that any member of the family has had. When you check an item, please note the FAMILY member's relationship to you. Relationship ADHD or Hyperactivity High Blood Pressure Anxiety or Worry Problem Huntington s Chorea Depression Kidney Disease Learning problems Mental Retardation Manic-Depressive Disorder Migraine Headaches Reading Problem Muscular Dystrophy Speech or Language Problem
4 Page 4 Multiple Sclerosis Sexual/physical abuse Nervous Breakdown or Problems Parkinson s Disease Alcoholism Physical Handicap or Disability Alzheimer s Disease Seizures or Epilepsy Birth Defect Sickle Cell Anemia Cancer Stroke Cerebral Palsy Suicide attempt Cystic Fibrosis Tay-Sachs Disease Diabetes Tourette s Syndrome or Tic Disorder Drug Addiction or Dependency Tuberculosis Heart Disease or Heart Attack Hemophilia Other Educational History Please list schools you have attended: School Dates Special Achievements (Degrees)/Problems (if any) Please list your work history (Current to oldest): Job Dates Special Achievement/Problems (if any) Additional Comments:
5 Page 5 Entrance Complaint For what reasons are you seeking help? What thoughts do you have regarding the possible causes of your issues? Is there anything else that I should know?
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