ADULT PATIENT HISTORY FORM. Name: Address: City: State: Zip: Occupation (if applicable): Religious Affiliation (if applicable):

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Transcription:

ADULT PATIENT HISTORY FORM DEMOGRAPHIC INFORMATION: Name: Address: City: State: Zip: Age: Date of Birth: Gender: Male Female Transgender Marital Status: Never Married Domestic Partners Married Separated Divorce Widowed Social Security #: Driver s License #/State: Education: G.E.D. High School Diploma Some College Associate s Bachelor s Graduate Degree Occupation (if applicable): Religious Affiliation (if applicable): Current reason(s) for seeking treatment: FAMILY INFORMATION: Name Occupation Education Religion Age Deceased? 1. Spouse: 2. Mother: 3. Father: 4. Siblings: 1

If applicable, please list any children you have and their ages: 4. Names of other persons living in the household and relationship to you (if applicable): MEDICAL & MENTAL HEALTH INFORMATION: 1. How would you rate your current physical health? (Please circle one) Poor Unsatisfactory Satisfactory Good Very Good Excellent 2. Please list any specific health problems you are currently experiencing: 3. Primary Care Physician s Name and Location: 4. Date and reason for most recent physical exam: 5. Current Prescription Medications: Name Date Started Dosage Frequency Purpose _ 4. 5. 6. Current Over-the-Counter Medications/Vitamins/Supplements: _ 2

7. Allergies: 8. Current Medical Conditions/Treatments: _ 4. 5. 9. Previous Surgeries and Dates: 10. Previous Hospitalizations and Dates: 11. Previous Medical Illnesses/Injuries, Treatments and Dates: 4. 5. 12. Have you received any type of mental health treatment in the past (i.e., psychotherapy, psychiatric services, etc.)? No Yes 13. If yes, please specify the nature of the treatment provided as well as the name and location of previous therapist/practitioner: 14. Have you ever been prescribed psychiatric medication? Yes No If yes, please list and provide dosage and dates: 3

15. Have you ever been hospitalized on an inpatient basis for psychiatric purposes? Yes No If yes, please provide dates and circumstances: 16. How would you rate your current sleeping habits? (Please circle one) Poor Unsatisfactory Satisfactory Good Very Good Excellent Please list any specific sleep problems you are currently experiencing: 17. How many times per week do you exercise? Type(s) of exercise: 18. Please list any difficulties you experience with your appetite or eating patterns and note recent weight loss/gain. 19. Are you currently experiencing overwhelming sadness, grief or depression? No Yes If yes, please explain symptoms and duration: 20. Are you currently experiencing anxiety, panic attacks, or have any fears? No Yes If yes, please explain symptoms and duration: 21. Are you currently experiencing any chronic physical pain? No Yes If yes, please describe. 22. How often do you consume alcoholic beverages? Drink(s) of choice: Daily Weekly Monthly Infrequently Never 4

23. How often do you engage in recreational drug use? Type(s): Daily Weekly Monthly Infrequently Never 24. Are you currently in a romantic relationship? No Yes If yes, for approximately how long? 25. On a scale of 1-10 (10 being optimal), how would you rate your current level of relationship satisfaction and why? 26. What significant life changes or stressful events have you experienced in the past? Recently? 27. Family s Mental Health History: In the section below, please identify if you have a family member who has any of the following. If yes, please indicate his or her relationship to you in the space provided (e.g., mother, father, grandmother, sibling, etc.) Alcohol/Substance Abuse No Yes Anxiety No Yes Depression No Yes Domestic Violence No Yes Eating Disorders No Yes Obsessive/Compulsive No Yes Schizophrenia/Psychosis No Yes Suicide Attempts No Yes Personality Disorders No Yes ADDITIONAL INFORMATION: 1. Are you currently employed? No Yes If yes, what is your current employment situation? 5

2. Do you enjoy your work? Is there anything stressful about your job? 3. Do you consider yourself to be spiritual or religious? No Yes If yes, please describe your faith or belief: 4. What do you consider to be some of your strengths? 5. What do you consider to be some of your limitations? 6. Please describe how you see yourself: 7. Please describe how you believe others see you: 8. What would you like to accomplish out of your time in therapy? 9. Please provide any comments or concerns that you may have or any additional information you would like your treatment provider to know about you: 6

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