problems/medications: Current supplements/vitamins/herbs: Past medical problems/medications: Other doctors/clinics seen regularly:

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Main Purpose of the consultation (Please give a brief summary of the main problems) What happened to make you seek evaluation at this time? MEDICAL HISTORY Current medical Prior Attempts to correct the problem/prior psychiatric history: (Please include contact with other professionals, medications, types of treatment, etc.) problems/medications: Current supplements/vitamins/herbs: Past medical problems/medications: Other doctors/clinics seen regularly: Any history of hitting your head, even if you don t lose consciousness? (e.g. car accident, hitting head on monkey bars, playing football, etc): Have you ever lost consciousness?

Have you been exposed to toxic substances? (e.g. furniture refinishing, agent orange, pesticides, etc) Ever had any seizures or seizure like activity? Prior hospitalizations (place, cause, date, outcome): Prior abnormal lab tests, X-rays, EEG, etc: Allergies/drug intolerances (describe): Do you have mold in your house? Do you have a carbon monoxide detector in your house? Yes No Do you have silver amalgam dental fillings? Yes No Present Height Present Weight Current Life Stresses: (include anything that is currently stressful for you, examples include relationships, job, school, finances, children) Prenatal and birth events: Your parents' attitudes toward their pregnancy with you Pregnancy complications (bleeding, excess vomiting, medication, infections, x-rays, smoking, alcohol/drug use, etc Any birth problems, trauma, forceps or complications? Sleep behavior: Is it hard for you to make yourself go to bed? Yes No Explain: How long does it take you to fall asleep? Do you stay asleep? Yes No Explain: Do you snore? Yes No Do you have sleepwalking, nightmares, night terrors, recurrent dreams, restless legs, talking in your sleep? School History: Last grade completed Last school attended Average grades received Specific learning disabilities

Learning strengths Any behavior problems in school? What have teachers said about you? Employment History: (summarize jobs you've had, list most favorite and least favorite) Any work-related problems? What would your employers or supervisors say about you? Military History? Ever Any Legal Problems? Alcohol and Drug History: (Please list age started and types of substances used through the years and any current usage. Also, describe how each of these substances made you feel; what benefit you got from them.). These include alcohol (hard liquor, beer, wine), marijuana or hash, prescription tranquilizers or sleeping pills, inhalants (glue, gasoline, cleaning fluids, etc.), cocaine or crack, amphetamines or crank or ice, steroids, opiates (heroin, codeine, morphine or other pain killers), barbiturates, hallucinating drugs (LSD, mescaline, mushrooms, PCP).

Do you or have you ever experienced withdrawal symptoms from alcohol or drugs? Has anyone told you they thought you had a problem with drugs or alcohol? Have you ever felt guilty about your drug or alcohol use? Have you ever felt annoyed when someone talked to you about your drug or alcohol use? Have you ever used drugs or alcohol first thing in the morning? Caffeine use per day (caffeine is in coffee, tea, sodas, chocolate) Nicotine use per day, past and present, (nicotine is in cigarettes, cigars, tobacco chew) Sexual history: (answer only as much as you feel comfortable) Primary Sexual Orientation: Gay, Straight, Bisexual Age at the time of first sexual experience: Number of sexual partners: Any history of sexually transmitted disease? History of abortion? History of sexual abuse, molestation or rape? Current sexual problems? Any history of being physically or sexually abused? Yes No FAMILY HISTORY Family Structure (who lives in your current household, please give relationship to each): Current Marital or Relationship Satisfaction Significant Life Events (include past and current marriages, separations, divorces, deaths, traumatic events, losses, abuse, etc.)

Natural Mother's History: age occupation School: highest grade completed Learning problems Behavior problems Marriages Medical Problems Childhood atmosphere (family position, abuse, illnesses, etc) Has mother ever sought psychiatric treatment? Yes No If yes, for what purpose? Mother's alcohol/drug use history Have any of your mother's blood relatives ever had any learning problems or psychiatric problems including such things as alcohol/drug abuse, depression, anxiety, suicide attempts, psychiatric hospitalizations? (specify) Natural Father's History: age occupation School: highest grade completed Learning problems Behavior problems Marriages Medical Problems Childhood atmosphere (family position, abuse, illnesses, etc) Has father ever sought psychiatric treatment? Yes No If yes, for what purpose?

Father's alcohol/drug use history: Have any of your father's blood relatives ever had any learning problems or psychiatric problems including such things as alcohol/drug abuse, depression, anxiety, suicide attempts, psychiatric hospitalizations? (specify) Siblings: Name Age relationship to patient Problems Strengths Cultural/Ethnic Background: Describe your relationships with friends: Describe yourself: Describe your strengths: What would you like to accomplish in your meeting?

Primary Insurance Information: Insurance Company name: Policy Number or Contract #: Group #: Social Security number of Policyholder: Employer Name: Name of Policyholder: Birth Date of Policyholder: Address of policyholder: City: State: Zip: Phone: Secondary Insurance Information: Insurance Company name: Policy Number or Contract #: Group #: Social Security number of Policyholder: Employer Name: Name of Policyholder: Birth Date of Policyholder: Address of policyholder: City: State: Zip: Phone: I understand as the primary responsible party, I will pay for all portions of charges that my insurance Company does not cover. I authorize the Center for Family Development to electronically transmit the claim to the insurance company, send any necessary documentation and discuss this case including diagnosis and other information from the clinical record with the insurance companies listed. I authorize my insurance company to send benefits directly to the Center for Family Development. In case of canceled appointments, I agree to provide 24 hours notice to the Center for Family Development or be responsible for a $30.00 missed appointment fee. Signature of Responsible Party: Date:

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